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General NPI Number Information
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NPI Number | 1659586477
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Entity Type | Individual
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Provider Name | MENSA KAMAUGOGO MUATA RSA
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Gender | Male
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 750 ALMAR PKWY SUITE 205
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City | BOURBONNAIS
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State | IL
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Zip | 60914-2315
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Country | US
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Telephone | 815-933-3955
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Fax | 815-933-3944
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Provider Business Mailing Address
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Address Line | 731 DOUBLE JACK ST APT F
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City | BOURBONNAIS
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State | IL
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Zip | 60914-9214
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Country | US
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Telephone | 815-549-2302
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Fax | 815-933-3944
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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 | 246ZS0410X
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Taxonomy Name | Surgical Technologist
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License Number |
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License Number State | IL
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