MEDICARE: MR. JACQUES KUBALUKA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	342000000X	Transportation Network Company

General Provider Information

NPI Number	:	1417633777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACQUES KUBALUKA

Provider Business Mailing Address
First Line	:	5501 JACKSBORO HWY STE 606
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1662
Country	:	US
Telephone Number	:	214-587-5763
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 JACKSBORO HWY STE 606
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1662
Country	:	US
Telephone Number	:	214-587-5763
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2023
Last Update Date	:	06/23/2023

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