Healthcare Provider Details

I. General information

NPI: 1912519125
Provider Name (Legal Business Name): VINCENT OBODE SOLE PROPRIETOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 EVERGREEN PL STE 604
EAST ORANGE NJ
07018-2021
US

IV. Provider business mailing address

134 EVERGREEN PL STE 604
EAST ORANGE NJ
07018-2021
US

V. Phone/Fax

Practice location:
  • Phone: 862-520-2029
  • Fax: 862-252-6836
Mailing address:
  • Phone: 862-520-2029
  • Fax: 862-252-6836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number26NO11868300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: