Healthcare Provider Details

I. General information

NPI: 1790597292
Provider Name (Legal Business Name): ENITE E OGHENEKARO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5504 102ND AVE N
BROOKLYN PARK MN
55443-2074
US

IV. Provider business mailing address

5504 102ND AVE N
BROOKLYN PARK MN
55443-2074
US

V. Phone/Fax

Practice location:
  • Phone: 651-283-4764
  • Fax: 763-374-4797
Mailing address:
  • Phone: 651-283-4764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: