Provider Demographics
NPI:1194790568
Name:HUBER, WAYNE ROBERT JR (DC, CCSP)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ROBERT
Last Name:HUBER
Suffix:JR
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 E FIGZEL CT
Mailing Address - Street 2:#104
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-2276
Mailing Address - Country:US
Mailing Address - Phone:605-498-5100
Mailing Address - Fax:605-498-5101
Practice Address - Street 1:725 E FIGZEL CT
Practice Address - Street 2:#104
Practice Address - City:TEA
Practice Address - State:SD
Practice Address - Zip Code:57064-2276
Practice Address - Country:US
Practice Address - Phone:605-498-5100
Practice Address - Fax:605-498-5101
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD935111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7604660Medicaid
SD7604660Medicaid
SD80961Medicare UPIN