Provider Demographics
NPI:1356084206
Name:OBANNER, CLIFFE
Entity Type:Individual
Prefix:
First Name:CLIFFE
Middle Name:
Last Name:OBANNER
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 1:14600 MONDOUBLEAU LN
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2314
Mailing Address - Country:US
Mailing Address - Phone:202-378-4864
Mailing Address - Fax:
Practice Address - Street 1:14600 MONDOUBLEAU LN
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-2314
Practice Address - Country:US
Practice Address - Phone:202-378-4864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company
No172A00000XOther Service ProvidersDriver