Healthcare Provider Details

I. General information

NPI: 1306442678
Provider Name (Legal Business Name): KELECHI ONWUCHEKWA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9005 W VERNON AVE
PHOENIX AZ
85037-3637
US

IV. Provider business mailing address

12228 W PIMA ST
AVONDALE AZ
85323-8105
US

V. Phone/Fax

Practice location:
  • Phone: 602-472-0105
  • Fax:
Mailing address:
  • Phone: 602-472-0105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: