MEDICARE: MRS. SUSAN OBENCHA MOGAKA JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	336921	TX

General Provider Information

NPI Number	:	1700369493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN OBENCHA MOGAKA JR.

Provider Business Mailing Address
First Line	:	8018 BLUE DUCK TRL
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-4494
Country	:	US
Telephone Number	:	720-589-0371
Fax Number	:

Provider Business Practice Location Address
First Line	:	8018 BLUE DUCK TRL
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-4494
Country	:	US
Telephone Number	:	720-589-0371
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2018
Last Update Date	:	09/10/2018

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