Healthcare Provider Details

I. General information

NPI: 1922428036
Provider Name (Legal Business Name): INDEPENDENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6406 BUSCH BLVD APT 461
COLUMBUS OH
43229-1853
US

IV. Provider business mailing address

6406 BUSCH BLVD APT 461
COLUMBUS OH
43229-1853
US

V. Phone/Fax

Practice location:
  • Phone: 216-313-0897
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberPN.155289-M-IV
License Number StateOH

VIII. Authorized Official

Name: ELVIS MBUNYA
Title or Position: L.P.N
Credential:
Phone: 216-313-0897