Healthcare Provider Details

I. General information

NPI: 1801895784
Provider Name (Legal Business Name): NED B HUBBARD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N TREMONT ST
KEWANEE IL
61443-0146
US

IV. Provider business mailing address

109 N TREMONT ST
KEWANEE IL
61443-0146
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-2236
  • Fax:
Mailing address:
  • Phone: 309-852-2236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007695
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: