Provider Demographics
NPI:1801197959
Name:ODJEGBA, RUKEVWE RICHARD (LPN)
Entity Type:Individual
Prefix:
First Name:RUKEVWE
Middle Name:RICHARD
Last Name:ODJEGBA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:OGHENERUKEVWE
Other - Middle Name:RICHARD
Other - Last Name:ODJEGBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:571 E 170TH ST
Mailing Address - Street 2:APT.4H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-2317
Mailing Address - Country:US
Mailing Address - Phone:646-764-4842
Mailing Address - Fax:
Practice Address - Street 1:571 E 170TH ST
Practice Address - Street 2:APT.4H
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-2317
Practice Address - Country:US
Practice Address - Phone:646-764-4842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302218164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse