MEDICARE: AMBONI HEALTHSOURCE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1073136800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMBONI HEALTHSOURCE LLC

Provider Business Mailing Address
First Line	:	25630 FARRIER DR
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-1468
Country	:	US
Telephone Number	:	214-830-9906
Fax Number	:

Provider Business Practice Location Address
First Line	:	25630 FARRIER DR
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-1468
Country	:	US
Telephone Number	:	214-830-9906
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	MR. PROSPER KISWAGA
Credential	:
Telephone Number	:	214-830-9906

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	06/13/2024

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