Provider Demographics
NPI:1114678711
Name:OMOGBEHIN, GOLD
Entity Type:Individual
Prefix:
First Name:GOLD
Middle Name:
Last Name:OMOGBEHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GOLD
Other - Middle Name:
Other - Last Name:OMOGBEHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1308 SNOWY EGRET DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-3227
Mailing Address - Country:US
Mailing Address - Phone:910-476-3859
Mailing Address - Fax:
Practice Address - Street 1:2665 JOHN SMITH RD STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-2623
Practice Address - Country:US
Practice Address - Phone:910-476-3859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2278H0200X
NCHC6427374U00000X, 2279H0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredHome Health
No2278H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide