Provider Demographics
NPI:1184068900
Name:TAKU, MBENG NDEMAZE (HOMEHEALTH AIDE)
Entity type:Individual
Prefix:
First Name:MBENG
Middle Name:NDEMAZE
Last Name:TAKU
Suffix:
Gender:M
Credentials:HOMEHEALTH AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W WENGER RD APT 177
Mailing Address - Street 2:APT 177
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1917
Mailing Address - Country:US
Mailing Address - Phone:937-931-3566
Mailing Address - Fax:
Practice Address - Street 1:711 W WENGER RD APT 177
Practice Address - Street 2:APT 177
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1917
Practice Address - Country:US
Practice Address - Phone:937-931-3566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide