Healthcare Provider Details

I. General information

NPI: 1689459828
Provider Name (Legal Business Name): VIRGILUS MAHAKWE OGBEDEAGU LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W 5TH ST
SANTA ANA CA
92701-4599
US

IV. Provider business mailing address

405 W 5TH ST
SANTA ANA CA
92701-4599
US

V. Phone/Fax

Practice location:
  • Phone: 714-834-3101
  • Fax:
Mailing address:
  • Phone: 714-834-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN729085
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: