1164804142 NPI number — MR. TODD MICHAEL KUBON BA, MAMS, CCA

Table of content: MR. TODD MICHAEL KUBON BA, MAMS, CCA (NPI 1164804142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164804142 NPI number — MR. TODD MICHAEL KUBON BA, MAMS, CCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUBON
Provider First Name:
TODD
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BA, MAMS, CCA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164804142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 NUTTALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60546-1804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-978-1073
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 NUTTALL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60546-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-978-1073
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 229N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 229N00000X . This is a "WPC CODE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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