Provider Demographics
NPI:1215486527
Name:AMEGAN, KODJO
Entity type:Individual
Prefix:
First Name:KODJO
Middle Name:
Last Name:AMEGAN
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 1:305 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2351
Mailing Address - Country:US
Mailing Address - Phone:719-671-0129
Mailing Address - Fax:
Practice Address - Street 1:305 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2351
Practice Address - Country:US
Practice Address - Phone:719-671-0129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer