Healthcare Provider Details

I. General information

NPI: 1811424724
Provider Name (Legal Business Name): JAY MICHAEL HUBER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10024 SE 240TH ST STE 220
KENT WA
98031-5124
US

IV. Provider business mailing address

10024 SE 240TH ST STE 220
KENT WA
98031-5124
US

V. Phone/Fax

Practice location:
  • Phone: 532-852-5440
  • Fax: 253-852-0272
Mailing address:
  • Phone: 532-852-5440
  • Fax: 253-852-0272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60769647
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: