Healthcare Provider Details

I. General information

NPI: 1629208418
Provider Name (Legal Business Name): FRANK MADUKA IFEDIBA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 GLENWAY DR
INGLEWOOD CA
90302-2711
US

IV. Provider business mailing address

826 GLENWAY DR
INGLEWOOD CA
90302-2711
US

V. Phone/Fax

Practice location:
  • Phone: 310-308-4094
  • Fax: 310-419-0840
Mailing address:
  • Phone: 310-308-4094
  • Fax: 310-419-0840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number569887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: