Provider Demographics
NPI:1215290572
Name:KEMBUMBARA, MIRABEAU
Entity type:Individual
Prefix:
First Name:MIRABEAU
Middle Name:
Last Name:KEMBUMBARA
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 1:621 SHERIDAN ST APT 24
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-3212
Mailing Address - Country:US
Mailing Address - Phone:240-505-7883
Mailing Address - Fax:
Practice Address - Street 1:7506 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1608
Practice Address - Country:US
Practice Address - Phone:202-291-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide