=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275397556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. EFETOBORE OMADEVUAE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2024
-----------------------------------------------------
Last Update Date | 02/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 PINEKNOT CT
-----------------------------------------------------
City | GWYNN OAK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21207-5585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-739-1209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6628 RIDGEBORNE DR
-----------------------------------------------------
City | ROSEDALE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21237-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-739-1209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------