Provider Demographics
NPI:1104103092
Name:MUNYABERA, METUSCHELAH
Entity type:Individual
Prefix:MR
First Name:METUSCHELAH
Middle Name:
Last Name:MUNYABERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14820 32ND ST
Mailing Address - Street 2:
Mailing Address - City:GOBLES
Mailing Address - State:MI
Mailing Address - Zip Code:49055-8648
Mailing Address - Country:US
Mailing Address - Phone:269-216-4230
Mailing Address - Fax:269-585-6009
Practice Address - Street 1:14820 32ND ST
Practice Address - Street 2:
Practice Address - City:GOBLES
Practice Address - State:MI
Practice Address - Zip Code:49055-8648
Practice Address - Country:US
Practice Address - Phone:269-216-4230
Practice Address - Fax:269-585-6009
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF800093261385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child