Provider Demographics
NPI:1730750746
Name:EGHIDEMWIVBIE, OSEMWEGIE (LMBT, AAS, PT)
Entity type:Individual
Prefix:
First Name:OSEMWEGIE
Middle Name:
Last Name:EGHIDEMWIVBIE
Suffix:
Gender:M
Credentials:LMBT, AAS, PT
Other - Prefix:
Other - First Name:SEMMIE
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMBT
Mailing Address - Street 1:100 PAVILION WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-4559
Mailing Address - Country:US
Mailing Address - Phone:919-520-9658
Mailing Address - Fax:
Practice Address - Street 1:100 PAVILION WAY
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-4559
Practice Address - Country:US
Practice Address - Phone:910-315-0402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17137225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty