Healthcare Provider Details

I. General information

NPI: 1740752062
Provider Name (Legal Business Name): JOHN KUBAI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27699 JEFFERSON AVE STE 111
TEMECULA CA
92590-2697
US

IV. Provider business mailing address

27699 JEFFERSON AVE STE 111
TEMECULA CA
92590-2697
US

V. Phone/Fax

Practice location:
  • Phone: 855-501-1004
  • Fax: 951-244-6014
Mailing address:
  • Phone: 855-501-1004
  • Fax: 951-244-6014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number263260
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95101149
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: