MEDICARE: JEFFREY ALLEN HUBBARD RPT

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	225100000X	Physical Therapist	PT21763	CA

General Provider Information

NPI Number	:	1790831840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY ALLEN HUBBARD RPT

Provider Business Mailing Address
First Line	:	16702 VALLEY VIEW AVE
Second Line	:
City	:	LA MIRADA
State	:	CA
Zip	:	90638-5824
Country	:	US
Telephone Number	:	714-367-5360
Fax Number	:	714-635-5428

Provider Business Practice Location Address
First Line	:	290 N 10TH ST STE 100
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-3052
Country	:	US
Telephone Number	:	909-264-2500
Fax Number	:	909-264-2510

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/03/2017

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