Provider Demographics
NPI:1942818786
Name:LEBUABANGA, IRENEE ABONEGI
Entity Type:Individual
Prefix:MR
First Name:IRENEE
Middle Name:ABONEGI
Last Name:LEBUABANGA
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 1:2669 GRAND COLONIAL ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0258
Mailing Address - Country:US
Mailing Address - Phone:817-992-9138
Mailing Address - Fax:
Practice Address - Street 1:2669 GRAND COLONIAL ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75054-0258
Practice Address - Country:US
Practice Address - Phone:817-992-9138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)