Provider Demographics
NPI:1437977543
Name:MUKUBA, CHARLES LWANGA
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LWANGA
Last Name:MUKUBA
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 1:211 NASHUA RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01862-3159
Mailing Address - Country:US
Mailing Address - Phone:248-635-9518
Mailing Address - Fax:
Practice Address - Street 1:211 NASHUA RD
Practice Address - Street 2:
Practice Address - City:NORTH BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01862-3159
Practice Address - Country:US
Practice Address - Phone:248-635-9518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA382299394251E00000X
MA$$$$$$$$$3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No251E00000XAgenciesHome Health