Healthcare Provider Details

I. General information

NPI: 1750050662
Provider Name (Legal Business Name): ERIC OBIAJURU UWAGBOI BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N RAYMOND AVE
PASADENA CA
91103
US

IV. Provider business mailing address

2327 GRANDEUR AVE
ALTADENA CA
91001-9100
US

V. Phone/Fax

Practice location:
  • Phone: 626-396-5920
  • Fax:
Mailing address:
  • Phone: 626-807-3996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: