Provider Demographics
NPI:1477270924
Name:PUGH, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:PUGH
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 1:1135 S MAIN ST STE 215
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-4750
Mailing Address - Country:US
Mailing Address - Phone:501-539-5015
Mailing Address - Fax:
Practice Address - Street 1:16581 FREELAND ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-4058
Practice Address - Country:US
Practice Address - Phone:313-400-3531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriver
No171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Multi-Specialty
No171WV0202XOther Service ProvidersContractorVehicle Modifications
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities