1760507248 NPI number — CLEMENT ETINAYAGOMWAN AGHEDO

Table of content: (NPI 1760507248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760507248 NPI number — CLEMENT ETINAYAGOMWAN AGHEDO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEMENT ETINAYAGOMWAN AGHEDO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1760507248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92377-0129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-882-2640
Provider Business Mailing Address Fax Number:
909-882-2648

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
248 E HIGHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92404-3703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-882-2640
Provider Business Practice Location Address Fax Number:
909-882-2648
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AGHEDO
Authorized Official First Name:
CLEMENT
Authorized Official Middle Name:
ETINAYAGOMWAN
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
909-882-2640

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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