Healthcare Provider Details

I. General information

NPI: 1457036337
Provider Name (Legal Business Name): KENNEDY OTIENO OYALO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9858 E HAY LOFT DR
FLORENCE AZ
85132-7369
US

IV. Provider business mailing address

9858 E HAY LOFT DR
FLORENCE AZ
85132-7369
US

V. Phone/Fax

Practice location:
  • Phone: 480-578-3995
  • Fax:
Mailing address:
  • Phone: 480-578-3995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number11745797
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number11745797
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: