Provider Demographics
NPI:1093981029
Name:ODEGA, EUGENE NKEM
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:NKEM
Last Name:ODEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 W GARDENA BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-5923
Mailing Address - Country:US
Mailing Address - Phone:310-962-7922
Mailing Address - Fax:323-757-3024
Practice Address - Street 1:1204 W GARDENA BLVD STE B
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-5923
Practice Address - Country:US
Practice Address - Phone:310-962-7922
Practice Address - Fax:310-767-7835
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49321OtherHOME MEDICAL DEVICE RETAIL LICENSE
CA49321OtherHOME MEDICAL DEVICE RETAIL LICENSE