Basic Information
| Provider Information | |||||||||
| NPI: | 1801916838 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MBONG | ||||||||
| FirstName: | FRANCIS | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MHR CM-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MBONG | ||||||||
| OtherFirstName: | FRANCIS | ||||||||
| OtherMiddleName: | BENEDICT | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MHR CM-A | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 508 VERREAUX DR | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730728182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058012335 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 909 ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730715229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055733973 | ||||||||
| FaxNumber: | 4055738245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 7527 | OK | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.