Healthcare Provider Details

I. General information

NPI: 1255264917
Provider Name (Legal Business Name): ALEX JOSEPH KUBIAK RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E GREENWAY PKWY APT 1002
PHOENIX AZ
85022-2528
US

IV. Provider business mailing address

110 E GREENWAY PKWY APT 1002
PHOENIX AZ
85022-2528
US

V. Phone/Fax

Practice location:
  • Phone: 815-681-0638
  • Fax:
Mailing address:
  • Phone: 815-681-0638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: