Provider Demographics
NPI:1750946984
Name:OBOSO, WENESH M (CEO)
Entity type:Individual
Prefix:MR
First Name:WENESH
Middle Name:M
Last Name:OBOSO
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:WENESH
Other - Middle Name:M
Other - Last Name:OBOSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CEO
Mailing Address - Street 1:3301 RIDGWAY RD APT B6
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7434
Mailing Address - Country:US
Mailing Address - Phone:870-592-0803
Mailing Address - Fax:870-879-9660
Practice Address - Street 1:3301 RIDGWAY RD APT B6
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7434
Practice Address - Country:US
Practice Address - Phone:870-592-0803
Practice Address - Fax:870-879-9660
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR097782163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice