Provider Demographics
NPI:1205528635
Name:BAMGBALA, MUTIAT B (PROVIDER)
Entity type:Individual
Prefix:
First Name:MUTIAT
Middle Name:B
Last Name:BAMGBALA
Suffix:
Gender:F
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 FAITH RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28146-7007
Mailing Address - Country:US
Mailing Address - Phone:860-986-0003
Mailing Address - Fax:
Practice Address - Street 1:254 ASHFIELD LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-8348
Practice Address - Country:US
Practice Address - Phone:860-986-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000048761695342000000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No342000000XTransportation ServicesTransportation Network Company