Healthcare Provider Details

I. General information

NPI: 1295390532
Provider Name (Legal Business Name): MATTHEW JEROME LAUBE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N HIGH ST
MOUNT ORAB OH
45154-9158
US

IV. Provider business mailing address

116 N HIGH ST
MOUNT ORAB OH
45154-9158
US

V. Phone/Fax

Practice location:
  • Phone: 937-444-6127
  • Fax: 937-444-6192
Mailing address:
  • Phone: 937-444-6127
  • Fax: 937-444-6192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberOCPSA161406
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: