Provider Demographics
NPI:1790231249
Name:SALAZAR, JEREMY JOHNNY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JOHNNY
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1123
Mailing Address - Street 2:
Mailing Address - City:ABIQUIU
Mailing Address - State:NM
Mailing Address - Zip Code:87510-1123
Mailing Address - Country:US
Mailing Address - Phone:505-927-9890
Mailing Address - Fax:
Practice Address - Street 1:21230 HWY 84
Practice Address - Street 2:
Practice Address - City:ABIQUIU
Practice Address - State:NM
Practice Address - Zip Code:87510
Practice Address - Country:US
Practice Address - Phone:505-927-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other