Healthcare Provider Details

I. General information

NPI: 1780289561
Provider Name (Legal Business Name): VICTOR NKEM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

18427 N 33RD AVE
PHOENIX AZ
85053-1050
US

IV. Provider business mailing address

8708 W WASHINGTON ST
TOLLESON AZ
85353-1351
US

V. Phone/Fax

Practice location:
  • Phone: 843-424-7508
  • Fax:
Mailing address:
  • Phone: 520-302-6217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number249812
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: