Healthcare Provider Details

I. General information

NPI: 1750245767
Provider Name (Legal Business Name): NKEMAKOLAM MAXWELL IROEGBLAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2025
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 W BLOOMFIELD RD
PHOENIX AZ
85029-2538
US

IV. Provider business mailing address

2509 W BLOOMFIELD RD
PHOENIX AZ
85029-2538
US

V. Phone/Fax

Practice location:
  • Phone: 480-577-9460
  • Fax:
Mailing address:
  • Phone: 480-577-9460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: