Provider Demographics
NPI:1346918141
Name:EJIM, OBIAGELI PHILOMENA
Entity Type:Individual
Prefix:MRS
First Name:OBIAGELI
Middle Name:PHILOMENA
Last Name:EJIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 W 7TH ST APT 104
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1012 W 7TH ST APT 104
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6380
Practice Address - Country:US
Practice Address - Phone:909-541-6106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18941947132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager