Provider Demographics
NPI:1518768811
Name:KASAMBO, DEOTILA LUCAS
Entity type:Individual
Prefix:
First Name:DEOTILA
Middle Name:LUCAS
Last Name:KASAMBO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-1694
Mailing Address - Country:US
Mailing Address - Phone:301-326-9489
Mailing Address - Fax:
Practice Address - Street 1:1085 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-1694
Practice Address - Country:US
Practice Address - Phone:301-326-9489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-22
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant