Healthcare Provider Details

I. General information

NPI: 1326557919
Provider Name (Legal Business Name): RAY VICTOR OBASEKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 FINLEY RD STE 140
DOWNERS GROVE IL
60515-1179
US

IV. Provider business mailing address

925 WARWICK DR
MATTESON IL
60443-1998
US

V. Phone/Fax

Practice location:
  • Phone: 773-983-8005
  • Fax:
Mailing address:
  • Phone: 773-983-8005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209015745
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: