Provider Demographics
NPI:1174136881
Name:IRENEE A. LEBUABANGA
Entity type:Organization
Organization Name:IRENEE A. LEBUABANGA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IRENEE
Authorized Official - Middle Name:ABONEGI
Authorized Official - Last Name:LEBUABANGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-992-9138
Mailing Address - Street 1:2669 GRAND COLONIAL ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0258
Mailing Address - Country:US
Mailing Address - Phone:817-992-9138
Mailing Address - Fax:817-404-4727
Practice Address - Street 1:2669 GRAND COLONIAL ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75054-0258
Practice Address - Country:US
Practice Address - Phone:817-992-9138
Practice Address - Fax:817-404-4727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)