Healthcare Provider Details

I. General information

NPI: 1831642636
Provider Name (Legal Business Name): IFEATU OBOLI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 E FAIRVIEW LN
ESPANOLA NM
87532-2822
US

IV. Provider business mailing address

282 S CAMINO DEL PUEBLO STE 2C
BERNALILLO NM
87004-5913
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-1991
  • Fax:
Mailing address:
  • Phone: 505-385-4984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: