Healthcare Provider Details

I. General information

NPI: 1740974518
Provider Name (Legal Business Name): MARYANN NGOZI OBIDIKE MHM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E 10TH ST
CLAREMONT CA
91711-5909
US

IV. Provider business mailing address

4534 WYATT ROLAND WAY
RICHMOND TX
77406-2657
US

V. Phone/Fax

Practice location:
  • Phone: 909-621-8000
  • Fax:
Mailing address:
  • Phone: 337-534-3839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: