Provider Demographics
NPI:1659890499
Name:IGUMBOR, KENNETH PAUL
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:PAUL
Last Name:IGUMBOR
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 1:1110 MOSS ROAD
Mailing Address - Street 2:SUITE 120B
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229
Mailing Address - Country:US
Mailing Address - Phone:614-772-1261
Mailing Address - Fax:
Practice Address - Street 1:1110 MOSS ROAD
Practice Address - Street 2:SUITE 120B
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229
Practice Address - Country:US
Practice Address - Phone:614-772-1261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3104A0630X, 172A00000X, 174200000X, 251E00000X, 251X00000X, 347C00000X, 372500000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No172A00000XOther Service ProvidersDriver
No174200000XOther Service ProvidersMeals
No251E00000XAgenciesHome Health
No251X00000XAgenciesSupports Brokerage
No347C00000XTransportation ServicesPrivate Vehicle
No372500000XNursing Service Related ProvidersChore Provider