Healthcare Provider Details

I. General information

NPI: 1164033411
Provider Name (Legal Business Name): MR. AMADIN OGBEBOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 09/28/2021
Certification Date: 09/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CREEKSIDE RIDGE CT STE 201-15
ROSEVILLE CA
95678-3595
US

IV. Provider business mailing address

101 CREEKSIDE RIDGE CT STE 201-15
ROSEVILLE CA
95678-3595
US

V. Phone/Fax

Practice location:
  • Phone: 916-458-1190
  • Fax:
Mailing address:
  • Phone: 916-458-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: