Provider Demographics
NPI:1629254925
Name:EBOTAGBORNDANG MBI
Entity Type:Organization
Organization Name:EBOTAGBORNDANG MBI
Other - Org Name:US CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EBOTAGBORNDANG
Authorized Official - Middle Name:
Authorized Official - Last Name:MBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-202-9177
Mailing Address - Street 1:3951 KIRBY DR
Mailing Address - Street 2:532
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76155-3925
Mailing Address - Country:US
Mailing Address - Phone:713-202-9177
Mailing Address - Fax:817-684-3829
Practice Address - Street 1:3951 KIRBY DR
Practice Address - Street 2:532
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76155-3925
Practice Address - Country:US
Practice Address - Phone:713-202-9177
Practice Address - Fax:817-684-3829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization