Healthcare Provider Details

I. General information

NPI: 1619503240
Provider Name (Legal Business Name): JOHNNY HULBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S 5TH AVE
HINES IL
60141-3030
US

IV. Provider business mailing address

EDWARD HINES JR VA HOSPITAL 5000 S 5TH AVENUE
HINES IL
60141
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-8387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number2062
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: