Provider Demographics
NPI:1609428481
Name:OSBORNE, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:OSBORNE
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:PO BOX 83
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27921-0083
Mailing Address - Country:US
Mailing Address - Phone:252-771-0033
Mailing Address - Fax:
Practice Address - Street 1:103 GENERALS WAY
Practice Address - Street 2:
Practice Address - City:SOUTH MILLS
Practice Address - State:NC
Practice Address - Zip Code:27976-9644
Practice Address - Country:US
Practice Address - Phone:252-771-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000045021575172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver