Healthcare Provider Details

I. General information

NPI: 1417687765
Provider Name (Legal Business Name): SOJI OBAGBEMI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 W CHARLESTON BLVD STE N
LAS VEGAS NV
89102-1651
US

IV. Provider business mailing address

3920 W CHARLESTON BLVD STE N
LAS VEGAS NV
89102-1651
US

V. Phone/Fax

Practice location:
  • Phone: 702-822-0447
  • Fax:
Mailing address:
  • Phone: 170-282-2044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: