Healthcare Provider Details

I. General information

NPI: 1568279214
Provider Name (Legal Business Name): GEORGE GBUBEMI JAJA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 12/16/2024
Certification Date: 12/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 FULTON AVE STE 101-53
SACRAMENTO CA
95821-5108
US

IV. Provider business mailing address

2740 FULTON AVE STE 101-53
SACRAMENTO CA
95821-5108
US

V. Phone/Fax

Practice location:
  • Phone: 702-372-5241
  • Fax:
Mailing address:
  • Phone: 702-372-5241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number8UWH688
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: