Provider Demographics
NPI:1073136800
Name:AMBONI HEALTHSOURCE LLC
Entity Type:Organization
Organization Name:AMBONI HEALTHSOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:PROSPER
Authorized Official - Middle Name:
Authorized Official - Last Name:KISWAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-830-9906
Mailing Address - Street 1:23438 AMOROSO ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-2069
Mailing Address - Country:US
Mailing Address - Phone:832-588-7556
Mailing Address - Fax:
Practice Address - Street 1:25630 FARRIER DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-1468
Practice Address - Country:US
Practice Address - Phone:214-830-9906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-27
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child