Provider Demographics
NPI:1912383613
Name:STUBBS, OWEN
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:
Last Name:STUBBS
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 1:8820 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-2204
Mailing Address - Country:US
Mailing Address - Phone:662-890-5454
Mailing Address - Fax:662-893-8343
Practice Address - Street 1:8820 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-2204
Practice Address - Country:US
Practice Address - Phone:662-890-5454
Practice Address - Fax:662-893-8343
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1246111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor