Healthcare Provider Details

I. General information

NPI: 1336317403
Provider Name (Legal Business Name): NKEM IHEANAJU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E 223RD ST SUITE 407
CARSON CA
90745-4355
US

IV. Provider business mailing address

PO BOX 1541
HAWTHORNE CA
90251-1541
US

V. Phone/Fax

Practice location:
  • Phone: 310-221-5310
  • Fax: 310-834-6119
Mailing address:
  • Phone: 310-221-5310
  • Fax: 310-834-6119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number103335
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number103335
License Number StateCA

VIII. Authorized Official

Name: MR. NKEM IHEANAJU
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 310-221-5310