Healthcare Provider Details

I. General information

NPI: 1417515925
Provider Name (Legal Business Name): EBENEZER OLUSEYE GBAROYE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1139 E JERSEY ST STE 417
ELIZABETH NJ
07201-2446
US

IV. Provider business mailing address

1614 CRESCENT AVE
HILLSIDE NJ
07205-1418
US

V. Phone/Fax

Practice location:
  • Phone: 973-704-7942
  • Fax: 908-345-5184
Mailing address:
  • Phone: 973-704-7942
  • 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: