Basic Information
| Provider Information | |||||||||
| NPI: | 1477184521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUNDENGA | ||||||||
| FirstName: | KEIKO | ||||||||
| MiddleName: | L. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 146 WOODLAND RD | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236632144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572774925 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6400 E BROAD ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432132086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146553345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2020 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1477184521 | 05 | OH | MEDICAID |