Provider Demographics
NPI:1609195411
Name:OMBORO, JACK OMONDI (LPN)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:OMONDI
Last Name:OMBORO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 PARKWAY PL
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-1823
Mailing Address - Country:US
Mailing Address - Phone:914-736-6207
Mailing Address - Fax:
Practice Address - Street 1:945 PARKWAY PL
Practice Address - Street 2:
Practice Address - City:PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10566-1823
Practice Address - Country:US
Practice Address - Phone:914-736-6207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292686164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse