Provider Demographics
NPI:1992457618
Name:TEGABONE, CLOVIS
Entity type:Individual
Prefix:
First Name:CLOVIS
Middle Name:
Last Name:TEGABONE
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 1:9120 CRANDALL RD
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-1929
Mailing Address - Country:US
Mailing Address - Phone:307-851-9357
Mailing Address - Fax:
Practice Address - Street 1:9120 CRANDALL RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-1929
Practice Address - Country:US
Practice Address - Phone:307-851-9357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide