Provider Demographics
NPI:1720384761
Name:RUBLE, ZACHARY KEITH (MED, ATC)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:KEITH
Last Name:RUBLE
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11130 PARKVIEW CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1735
Mailing Address - Country:US
Mailing Address - Phone:260-402-2633
Mailing Address - Fax:
Practice Address - Street 1:11130 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1735
Practice Address - Country:US
Practice Address - Phone:260-402-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002508A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer