Healthcare Provider Details

I. General information

NPI: 1154742963
Provider Name (Legal Business Name): KAZIM AGBAJE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2013
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 CHRISTY WAY
SPRING VALLEY CA
91977-2629
US

IV. Provider business mailing address

3111 CHRISTY WAY
SPRING VALLEY CA
91977-2629
US

V. Phone/Fax

Practice location:
  • Phone: 619-764-0150
  • Fax:
Mailing address:
  • Phone: 619-764-0150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number04177814
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: