Provider Demographics
NPI:1598105116
Name:MBACHU, COLUMBUS O (DPT)
Entity Type:Individual
Prefix:
First Name:COLUMBUS
Middle Name:O
Last Name:MBACHU
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 ALDERBROOK CT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2637
Mailing Address - Country:US
Mailing Address - Phone:219-663-6758
Mailing Address - Fax:219-769-6113
Practice Address - Street 1:300 W 80TH PL STE D
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5476
Practice Address - Country:US
Practice Address - Phone:219-769-6037
Practice Address - Fax:219-769-6113
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004975A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist