=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053861369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACHUCA MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2016
-----------------------------------------------------
Last Update Date | 12/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8648 OLD TROY PIKE STE A
-----------------------------------------------------
City | HUBER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45424-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-795-1101
-----------------------------------------------------
Fax | 937-795-1120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8648 OLD TROY PIKE STE A
-----------------------------------------------------
City | HUBER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45424-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-795-1101
-----------------------------------------------------
Fax | 937-795-1120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ SOLO PHYSICIAN
-----------------------------------------------------
Name | DR. JENNIFER LYNN MACHUCA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 937-795-1101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 92123
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------