Provider Demographics
NPI:1194726455
Name:AFAHA M ASANGANSI
Entity type:Organization
Organization Name:AFAHA M ASANGANSI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AFAHA
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:ASANGANSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-509-3987
Mailing Address - Street 1:7524 S BROADWAY AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5007
Mailing Address - Country:US
Mailing Address - Phone:903-509-3987
Mailing Address - Fax:903-509-9428
Practice Address - Street 1:7524 S BROADWAY AVE
Practice Address - Street 2:STE120
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5007
Practice Address - Country:US
Practice Address - Phone:903-509-3987
Practice Address - Fax:903-509-9428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX161161801332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4654720001Medicare NSC