Provider Demographics
NPI:1518102722
Name:AGBABUNE, ETETE L (MT)
Entity Type:Individual
Prefix:MS
First Name:ETETE
Middle Name:L
Last Name:AGBABUNE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:MS
Other - First Name:ETETE
Other - Middle Name:L
Other - Last Name:AGBABUNE-TORRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4920 UNIVERSITY SQ
Mailing Address - Street 2:SUITE F
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35816-1893
Mailing Address - Country:US
Mailing Address - Phone:256-837-6127
Mailing Address - Fax:256-837-2139
Practice Address - Street 1:4920 UNIVERSITY SQ.
Practice Address - Street 2:SUITE F
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-1893
Practice Address - Country:US
Practice Address - Phone:256-837-6127
Practice Address - Fax:256-837-2139
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1745225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-46177OtherBLUE CROSS BLUE SHIELD