1093981029 NPI number — EUGENE NKEM ODEGA

Table of content: ROCCO MICHAEL RACANELLI PA (NPI 1073509550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093981029 NPI number — EUGENE NKEM ODEGA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODEGA
Provider First Name:
EUGENE
Provider Middle Name:
NKEM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093981029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1715 W EL SEGUNDO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-755-8063
Provider Business Mailing Address Fax Number:
323-757-3024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1715 W EL SEGUNDO BLVD
Provider Second Line Business Practice Location Address:
SAME
Provider Business Practice Location Address City Name:
GARDENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90249-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-755-8063
Provider Business Practice Location Address Fax Number:
323-757-3024
Provider Enumeration Date:
04/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 172A00000X , with the licence number:  CO971395 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 49321 . This is a "HOME MEDICAL DEVICE RETAIL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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