Healthcare Provider Details

I. General information

NPI: 1245961663
Provider Name (Legal Business Name): FUTURE OGBEBOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 190TH ST STE 280
GARDENA CA
90248-4305
US

IV. Provider business mailing address

11401 BLOOMFIELD AVE
NORWALK CA
90650-2015
US

V. Phone/Fax

Practice location:
  • Phone: 310-515-8113
  • Fax:
Mailing address:
  • Phone: 562-863-7011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2021208165
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: