Healthcare Provider Details

I. General information

NPI: 1164087912
Provider Name (Legal Business Name): AGNES CHINWE OGBATUE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16302 SKYRIDGE DR
RIVERSIDE CA
92503-0564
US

IV. Provider business mailing address

16302 SKYRIDGE DR
RIVERSIDE CA
92503-0564
US

V. Phone/Fax

Practice location:
  • Phone: 951-858-8134
  • Fax:
Mailing address:
  • Phone: 951-858-8134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number677872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: