Provider Demographics
NPI:1558135574
Name:ISHENGOMA, TOM PLIVATUS
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:PLIVATUS
Last Name:ISHENGOMA
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 1:3430 BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2906
Mailing Address - Country:US
Mailing Address - Phone:614-966-0671
Mailing Address - Fax:
Practice Address - Street 1:19535 N 55TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6805
Practice Address - Country:US
Practice Address - Phone:614-966-0671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility