Basic Information
| Provider Information | |||||||||
| NPI: | 1588978498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUBER | ||||||||
| FirstName: | BLAZE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4101A VALLEY VIEW RD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787047994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129134743 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 CONGRESS AVE | ||||||||
| Address2: | STE L-VAULTS | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787012437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124671100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2010 | ||||||||
| LastUpdateDate: | 07/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2074248 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225700000X | MT046366 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.