Healthcare Provider Details

I. General information

NPI: 1265404081
Provider Name (Legal Business Name): PATRICK ADEBOWALE SOGBEIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13615 VICTORY BLVD SUITE136
VAN NUYS CA
91401-1737
US

IV. Provider business mailing address

13615 VICTORY BLVD SUITE 136
VAN NUYS CA
91401-1737
US

V. Phone/Fax

Practice location:
  • Phone: 818-376-1243
  • Fax: 818-376-1604
Mailing address:
  • Phone: 818-376-1243
  • Fax: 818-376-1604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number102908
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: