Provider Demographics
NPI:1194473363
Name:DUBOSE, KHALIF (MS LAT ATC)
Entity Type:Individual
Prefix:
First Name:KHALIF
Middle Name:
Last Name:DUBOSE
Suffix:
Gender:M
Credentials:MS LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 LIVINGSTON AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-3807
Mailing Address - Country:US
Mailing Address - Phone:732-470-7309
Mailing Address - Fax:
Practice Address - Street 1:1133 LIVINGSTON AVE APT 9
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-3807
Practice Address - Country:US
Practice Address - Phone:732-470-7309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT003038002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty