Provider Demographics
NPI:1013008663
Name:HUBBARD, LYNSEY HOWARD
Entity Type:Individual
Prefix:
First Name:LYNSEY
Middle Name:HOWARD
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 OLYMPIC DR
Mailing Address - Street 2:112
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3393
Mailing Address - Country:US
Mailing Address - Phone:951-278-4717
Mailing Address - Fax:951-272-2815
Practice Address - Street 1:1180 OLYMPIC DR
Practice Address - Street 2:112
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-3393
Practice Address - Country:US
Practice Address - Phone:951-278-4717
Practice Address - Fax:951-272-2815
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0014970Medicaid
CAXA0014970Medicaid