Provider Demographics
NPI:1467281097
Name:AGBOR, THEOPHILUS AGBOR (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:THEOPHILUS
Middle Name:AGBOR
Last Name:AGBOR
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13874 PALOMINO CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-8966
Mailing Address - Country:US
Mailing Address - Phone:323-809-9708
Mailing Address - Fax:
Practice Address - Street 1:13874 PALOMINO CREEK DR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92883-8966
Practice Address - Country:US
Practice Address - Phone:323-809-9708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95213247163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse