=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093502379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC MBA NGONO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2025
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6200 WESTCHESTER PARK DR
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20740-2853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-286-4994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6200 WESTCHESTER PARK DR APT 603
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20740-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-286-4994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------