Provider Demographics
NPI:1124711759
Name:KOULBOU, MOUSSA
Entity type:Individual
Prefix:
First Name:MOUSSA
Middle Name:
Last Name:KOULBOU
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 1:3241 S HORIZON PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-3718
Mailing Address - Country:US
Mailing Address - Phone:480-747-2977
Mailing Address - Fax:
Practice Address - Street 1:10031 E DYNAMITE BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-3719
Practice Address - Country:US
Practice Address - Phone:480-747-2977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)