1518102722 NPI number — MS. ETETE L. AGBABUNE MT

Table of content: MS. ETETE L. AGBABUNE MT (NPI 1518102722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518102722 NPI number — MS. ETETE L. AGBABUNE MT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGBABUNE
Provider First Name:
ETETE
Provider Middle Name:
L.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AGBABUNE-TORRES
Provider Other First Name:
ETETE
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518102722
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11551
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35814-1551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-326-0890
Provider Business Mailing Address Fax Number:
256-289-2640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3303 WESTMILL DR SW STE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35805-6133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-326-0890
Provider Business Practice Location Address Fax Number:
256-326-0890
Provider Enumeration Date:
12/03/2008

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: 225700000X , with the licence number:  1745 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 515-46177 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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