Provider Demographics
NPI:1437974706
Name:ITA, EYOBONG
Entity type:Individual
Prefix:
First Name:EYOBONG
Middle Name:
Last Name:ITA
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:PO BOX 29646
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229
Mailing Address - Country:US
Mailing Address - Phone:614-973-3230
Mailing Address - Fax:
Practice Address - Street 1:636 SALISBURY ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204
Practice Address - Country:US
Practice Address - Phone:614-973-3230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDD00139670251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health