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General NPI Number Information
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NPI Number | 1487126652
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Entity Type | Individual
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Provider Name | JACOB RIBA
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Gender | Male
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Dates
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Enumeration Date | 12/27/2018
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Last Update Date | 12/27/2018
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Provider Practice Location Address
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Address Line | 201 DONAGHEY AVE
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City | CONWAY
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State | AR
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Zip | 72035-5001
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Country | US
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Telephone | 501-450-5112
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Fax |
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Provider Business Mailing Address
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Address Line | 6625 FOXRUN EAST END DR
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City | MABELVALE
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State | AR
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Zip | 72103-9456
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Country | US
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Telephone | 501-529-4951
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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