Provider Demographics
NPI:1548094428
Name:LE, JEREMY THACH
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:THACH
Last Name:LE
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 1:13433 ROBLEY RANCH RD
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-7009
Mailing Address - Country:US
Mailing Address - Phone:858-231-1447
Mailing Address - Fax:
Practice Address - Street 1:2650 CAMINO DEL RIO N STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1631
Practice Address - Country:US
Practice Address - Phone:619-295-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-31
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53447225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant