Healthcare Provider Details

I. General information

NPI: 1750946984
Provider Name (Legal Business Name): WENESH M. OBOSO CEO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WENESH M OBOSO CEO

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 RIDGWAY RD APT B6
PINE BLUFF AR
71603-7434
US

IV. Provider business mailing address

3301 RIDGWAY RD APT B6
PINE BLUFF AR
71603-7434
US

V. Phone/Fax

Practice location:
  • Phone: 870-592-0803
  • Fax: 870-879-9660
Mailing address:
  • Phone: 870-592-0803
  • Fax: 870-879-9660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberR097782
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: