Provider Demographics
NPI:1871950782
Name:EDIBA, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:EDIBA
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 1:273 KEYSTONE DR APT 5
Mailing Address - Street 2:
Mailing Address - City:RANTOUL
Mailing Address - State:IL
Mailing Address - Zip Code:61866-2774
Mailing Address - Country:US
Mailing Address - Phone:217-418-7384
Mailing Address - Fax:
Practice Address - Street 1:273 KEYSTONE DR APT 5
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866-2774
Practice Address - Country:US
Practice Address - Phone:217-418-7384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILMCS-10-0005-0464R1343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)