Healthcare Provider Details

I. General information

NPI: 1497291116
Provider Name (Legal Business Name): GUSTAVO URBINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4623 75TH ST SUITE 279
KENOSHA WI
53142-3701
US

IV. Provider business mailing address

4623 75TH ST SUITE 279
KENOSHA WI
53142-3701
US

V. Phone/Fax

Practice location:
  • Phone: 773-495-3796
  • Fax:
Mailing address:
  • Phone: 773-495-3796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: