Healthcare Provider Details

I. General information

NPI: 1174332084
Provider Name (Legal Business Name): AURELE M TIOGOUONG MAFOUO ATM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/06/2025
Certification Date: 01/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4869 KINGSHILL DR APT 209
COLUMBUS OH
43229-6263
US

IV. Provider business mailing address

4869 KINGSHILL DR APT 209
COLUMBUS OH
43229-6263
US

V. Phone/Fax

Practice location:
  • Phone: 443-410-8102
  • Fax:
Mailing address:
  • Phone: 443-410-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number652326-DD00296558
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number652326-DD00296558
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number652326-DD00296558
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number652326-DD00296558
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: