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NPI Code Detail

MEDICARE: JACOB RANDAL HUBER

MEDICARE: JACOB RANDAL HUBER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior TechnicianMI

General Provider Information

NPI Number : 1184130460
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB RANDAL HUBER
Provider Business Mailing Address
First Line : 4543 DIX ST
Second Line :
City : LUNA PIER
State : MI
Zip : 48157-9768
Country : US
Telephone Number : 419-699-0536
Fax Number :
Provider Business Practice Location Address
First Line : 1360 PORTER ST
Second Line :
City : DEARBORN
State : MI
Zip : 48124-2890
Country : US
Telephone Number : 313-689-5188
Fax Number : 866-861-5188
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/21/2017
Last Update Date : 12/21/2017

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