Healthcare Provider Details

I. General information

NPI: 1518276245
Provider Name (Legal Business Name): MR. EMMANUEL I OGBOLU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11615 FOREST CENTRAL DR SUITE 321
DALLAS TX
75243-5905
US

IV. Provider business mailing address

11615 FOREST CENTRAL DR SUITE 321
DALLAS TX
75243-5905
US

V. Phone/Fax

Practice location:
  • Phone: 214-342-8888
  • Fax: 214-342-9999
Mailing address:
  • Phone: 214-342-8888
  • Fax: 214-342-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: