Provider Demographics
NPI:1922428036
Name:INDEPENDENT
Entity Type:Organization
Organization Name:INDEPENDENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:L.P.N
Authorized Official - Prefix:
Authorized Official - First Name:ELVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MBUNYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-313-0897
Mailing Address - Street 1:6406 BUSCH BLVD APT 461
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-1853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6406 BUSCH BLVD APT 461
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-1853
Practice Address - Country:US
Practice Address - Phone:216-313-0897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.155289-M-IV311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home