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General NPI Number Information
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NPI Number | 1558673376
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Entity Type | Individual
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Provider Name | MFOMBU AYUKESONG CSA
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Gender | Male
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Dates
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Enumeration Date | 07/09/2010
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Last Update Date | 07/09/2010
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Provider Practice Location Address
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Address Line | 14828 ARTESIAN AVE
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City | HARVEY
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State | IL
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Zip | 60426-1313
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Country | US
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Telephone | 708-566-4328
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Fax | 708-589-3372
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Provider Business Mailing Address
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Address Line | PO BOX 44
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City | POSEN
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State | IL
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Zip | 60469-0044
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Country | US
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Telephone | 708-566-4328
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Fax | 708-589-3372
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 2380000263
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License Number State | IL
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