1619952793 NPI number — RICHARD JEREMY HUBBARD PT

Table of content: RICHARD JEREMY HUBBARD PT (NPI 1619952793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619952793 NPI number — RICHARD JEREMY HUBBARD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUBBARD
Provider First Name:
RICHARD
Provider Middle Name:
JEREMY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1619952793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5962 LA PLACE CT
Provider Second Line Business Mailing Address:
SUITE 170
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92008-8807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-929-4776
Provider Business Mailing Address Fax Number:
760-931-8370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11276 5TH ST
Provider Second Line Business Practice Location Address:
NUMBER 400
Provider Business Practice Location Address City Name:
RANCHO CUCAMONGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91730-0921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-987-1116
Provider Business Practice Location Address Fax Number:
909-987-0126
Provider Enumeration Date:
12/12/2005

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: 225100000X , with the licence number:  PT30033 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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