Healthcare Provider Details

I. General information

NPI: 1609326495
Provider Name (Legal Business Name): MR. KELVIN OGHENERUEMU KOBODJE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 FEDERAL ST
CAMDEN NJ
08103-1121
US

IV. Provider business mailing address

330 FEDERAL ST
CAMDEN NJ
08103-1121
US

V. Phone/Fax

Practice location:
  • Phone: 856-580-5733
  • Fax: 856-225-7650
Mailing address:
  • Phone: 856-580-5733
  • Fax: 856-225-7650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: