Healthcare Provider Details

I. General information

NPI: 1437351244
Provider Name (Legal Business Name): OGBAN O OGBU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 E CARSON PLAZA DR STE 120
CARSON CA
90746-3272
US

IV. Provider business mailing address

22727 JODY LN
CARSON CA
90745-3603
US

V. Phone/Fax

Practice location:
  • Phone: 310-856-5799
  • Fax: 310-856-5798
Mailing address:
  • Phone: 310-787-0586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: