Healthcare Provider Details

I. General information

NPI: 1023924677
Provider Name (Legal Business Name): THEOPHILE MOISE NGOUPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 GREEN MEADOWS DR E APT C
GAHANNA OH
43230-2741
US

IV. Provider business mailing address

107 GREEN MEADOWS DR E APT C
GAHANNA OH
43230-2741
US

V. Phone/Fax

Practice location:
  • Phone: 240-535-9780
  • Fax:
Mailing address:
  • Phone: 240-535-9780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number603028790525
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: