Healthcare Provider Details

I. General information

NPI: 1619942695
Provider Name (Legal Business Name): EBENEZER OGUNTUASE RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E LANDIS AVE
VINELAND NJ
08360-8004
US

IV. Provider business mailing address

611 E LANDIS AVE
VINELAND NJ
08360-8004
US

V. Phone/Fax

Practice location:
  • Phone: 856-794-2100
  • Fax: 856-794-2120
Mailing address:
  • Phone: 856-794-2100
  • Fax: 856-794-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00598500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: