Provider Demographics
NPI:1003228016
Name:HUBBARD, GROVER L JR (LMT)
Entity Type:Individual
Prefix:
First Name:GROVER
Middle Name:L
Last Name:HUBBARD
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SWEET HOME
Mailing Address - State:OR
Mailing Address - Zip Code:97386-1608
Mailing Address - Country:US
Mailing Address - Phone:541-913-9501
Mailing Address - Fax:541-367-8093
Practice Address - Street 1:1262 MAIN ST
Practice Address - Street 2:
Practice Address - City:SWEET HOME
Practice Address - State:OR
Practice Address - Zip Code:97386-1608
Practice Address - Country:US
Practice Address - Phone:541-913-9501
Practice Address - Fax:541-367-8093
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-24
Last Update Date:2014-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20473174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist