Healthcare Provider Details

I. General information

NPI: 1922368216
Provider Name (Legal Business Name): MR. TAJ YUSEF HUBBARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12430 DOWNY BIRCH RD
CHARLOTTE NC
28227-3675
US

IV. Provider business mailing address

12430 DOWNY BIRCH RD
CHARLOTTE NC
28227-3675
US

V. Phone/Fax

Practice location:
  • Phone: 704-606-5013
  • Fax:
Mailing address:
  • Phone: 704-606-5013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: