Provider Demographics
NPI:1700475092
Name:ADOM, CANICE NDUBISI
Entity Type:Individual
Prefix:
First Name:CANICE
Middle Name:NDUBISI
Last Name:ADOM
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 1:407 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-2652
Mailing Address - Country:US
Mailing Address - Phone:510-200-5147
Mailing Address - Fax:
Practice Address - Street 1:407 E 10TH ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-2652
Practice Address - Country:US
Practice Address - Phone:510-200-5147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF5277294172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver