Provider Demographics
NPI:1598138364
Name:ELVIS MBAH
Entity Type:Organization
Organization Name:ELVIS MBAH
Other - Org Name:INDEPENDENT PROVIDER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOMECARE
Authorized Official - Prefix:MR
Authorized Official - First Name:ELVIS
Authorized Official - Middle Name:N
Authorized Official - Last Name:MBAH
Authorized Official - Suffix:
Authorized Official - Credentials:STNA
Authorized Official - Phone:513-693-3593
Mailing Address - Street 1:3265 ROCKER DR APT 4
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45239-4154
Mailing Address - Country:US
Mailing Address - Phone:513-693-3593
Mailing Address - Fax:
Practice Address - Street 1:3265 ROCKER DR APT 4
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-4154
Practice Address - Country:US
Practice Address - Phone:513-693-3593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121325Medicaid