Provider Demographics
NPI:1316194103
Name:MBEKE-EKANEM, TOM E
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:E
Last Name:MBEKE-EKANEM
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:PO BOX 1231
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92502-1231
Mailing Address - Country:US
Mailing Address - Phone:951-354-5151
Mailing Address - Fax:951-354-0809
Practice Address - Street 1:9438 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3746
Practice Address - Country:US
Practice Address - Phone:951-354-5151
Practice Address - Fax:951-354-0809
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17498332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6121970001Medicare NSC