Healthcare Provider Details

I. General information

NPI: 1629465273
Provider Name (Legal Business Name): KINGSLEY O. OFOEGBU MD, FACP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 E REGENT ST STE 200
INGLEWOOD CA
90301-1444
US

IV. Provider business mailing address

20111 WADLEY AVE
CARSON CA
90746-3046
US

V. Phone/Fax

Practice location:
  • Phone: 310-982-3141
  • Fax:
Mailing address:
  • Phone: 310-982-3141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number688400
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number688400
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number688400
License Number StateCA

VIII. Authorized Official

Name: MR. SEBASTINE E. CHIKEZIE
Title or Position: NURSE PRACTITIONER
Credential: N.P.
Phone: 310-982-3141