Provider Demographics
NPI:1275866881
Name:MUTUMBA, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MUTUMBA
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 1:9807 WORNALL RD
Mailing Address - Street 2:#D
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-3986
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9807 WORNALL RD
Practice Address - Street 2:#D
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-3986
Practice Address - Country:US
Practice Address - Phone:816-589-7475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist