Provider Demographics
NPI:1891351292
Name:ETUKUMOH, KINGSLEY ANDRIS
Entity Type:Individual
Prefix:
First Name:KINGSLEY
Middle Name:ANDRIS
Last Name:ETUKUMOH
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 1:1400 LLOYD RD UNIT 164
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-8605
Mailing Address - Country:US
Mailing Address - Phone:216-357-1578
Mailing Address - Fax:
Practice Address - Street 1:2260 PAR LN APT 812
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-2949
Practice Address - Country:US
Practice Address - Phone:216-357-1578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)