Healthcare Provider Details

I. General information

NPI: 1285442178
Provider Name (Legal Business Name): DECLAN C MGBUDEM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17403 HARVARD AVE
CLEVELAND OH
44128-1715
US

IV. Provider business mailing address

10449 TOWNLEY CT
REMINDERVILLE OH
44202-8152
US

V. Phone/Fax

Practice location:
  • Phone: 234-389-2121
  • Fax:
Mailing address:
  • Phone: 234-389-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberSS802996
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: