Provider Demographics
NPI:1225626864
Name:IBARRA, CALEB J
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:J
Last Name:IBARRA
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 1:8710 TARIN PT
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3461
Mailing Address - Country:US
Mailing Address - Phone:865-298-4260
Mailing Address - Fax:
Practice Address - Street 1:8710 TARIN PT
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-3461
Practice Address - Country:US
Practice Address - Phone:865-298-4260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker