Provider Demographics
NPI:1114153095
Name:MBANG, EMMANUEL
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:MBANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3402 BAKER BLVD # A-3
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-2509
Mailing Address - Country:US
Mailing Address - Phone:225-774-7476
Mailing Address - Fax:
Practice Address - Street 1:3402 BAKER BLVD # A-3
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-2509
Practice Address - Country:US
Practice Address - Phone:225-774-7476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
15138253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1656968Medicaid