Healthcare Provider Details

I. General information

NPI: 1790193472
Provider Name (Legal Business Name): ROSETTE ADEGBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2014
Last Update Date: 07/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1084 FLAGER RANCH RD
CORONA CA
92881-4730
US

IV. Provider business mailing address

1084 FLAGER RANCH RD
CORONA CA
92881-4730
US

V. Phone/Fax

Practice location:
  • Phone: 951-549-6912
  • Fax: 951-817-9041
Mailing address:
  • Phone: 951-549-6912
  • Fax: 951-817-9041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberF0714839
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License NumberF0714839
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberF0714829
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberF0714839
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROSETTE JONATHAN ADEGBE
Title or Position: FNP
Credential: NP-C
Phone: 323-806-5783