1033740824 NPI number — MR. SAMUEL AGYENIM BOATENG CNP

Table of content: MR. SAMUEL AGYENIM BOATENG CNP (NPI 1033740824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033740824 NPI number — MR. SAMUEL AGYENIM BOATENG CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOATENG
Provider First Name:
SAMUEL
Provider Middle Name:
AGYENIM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033740824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
144 BRANDYWINE DR APT B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43081-1379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-806-8865
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HOLY HILLS HEALTHCARE SERVICES, LLC
Provider Second Line Business Practice Location Address:
6760 TUSSING ROAD SUITE 104
Provider Business Practice Location Address City Name:
REYNOLDSBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43068-4136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-626-6000
Provider Business Practice Location Address Fax Number:
614-577-0807
Provider Enumeration Date:
01/30/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APRN.CNP.025942 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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