Provider Demographics
NPI:1295134666
Name:NDENGA, ELISEE
Entity type:Individual
Prefix:
First Name:ELISEE
Middle Name:
Last Name:NDENGA
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 1:442 STONE SHADOW DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8097
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:442 STONE SHADOW DR
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004
Practice Address - Country:US
Practice Address - Phone:614-218-5743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171WV0202XOther Service ProvidersContractorVehicle Modifications