Healthcare Provider Details

I. General information

NPI: 1104694678
Provider Name (Legal Business Name): ANGELA F OGBEBOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date: 12/18/2023
Reactivation Date: 05/12/2026

III. Provider practice location address

801 CORPORATE CENTER DR STE 210
POMONA CA
91768-2627
US

IV. Provider business mailing address

11852 MOUNT VERNON AVE # M473
GRAND TERRACE CA
92313-8207
US

V. Phone/Fax

Practice location:
  • Phone: 909-634-3974
  • Fax:
Mailing address:
  • Phone: 951-603-8468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: