Basic Information
| Provider Information | |||||||||
| NPI: | 1083040745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEBONG | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | HHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13920 CASTLE BLVD APT 502 | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209044959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025450935 | ||||||||
| FaxNumber: | 2025450176 | ||||||||
| Practice Location | |||||||||
| Address1: | 13920 CASTLE BLVD APT 502 | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209044959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025450935 | ||||||||
| FaxNumber: | 2025450176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2013 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 374U00000X | Y | Nursing Service Related Providers | Home Health Aide |
No ID Information.