Healthcare Provider Details

I. General information

NPI: 1194369264
Provider Name (Legal Business Name): SIMEON SOBENNA EKUGWUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2439 MANHATTAN BLVD STE 308
HARVEY LA
70058-5396
US

IV. Provider business mailing address

18 ROB LN
JACKSON MS
39212-5927
US

V. Phone/Fax

Practice location:
  • Phone: 504-366-5265
  • Fax:
Mailing address:
  • Phone: 601-842-0971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPLC9826
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: