=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083152854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUBBARD HOUSE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2017
-----------------------------------------------------
Last Update Date | 02/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7901 HENRY AVE APT F105
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-3054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-408-6417
-----------------------------------------------------
Fax | 267-766-5965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7901 HENRY AVE APT F105
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-3054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-408-6417
-----------------------------------------------------
Fax | 267-766-5965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/ LPN
-----------------------------------------------------
Name | MS. RITA HUBBARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 267-408-6417
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | PN084112L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------