Healthcare Provider Details

I. General information

NPI: 1538887567
Provider Name (Legal Business Name): IFEANYICHUKWU ONUBAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7765 LEEDS ST
DOWNEY CA
90242-3489
US

IV. Provider business mailing address

21509 S PERALTA DR
CARSON CA
90745-1658
US

V. Phone/Fax

Practice location:
  • Phone: 844-804-1933
  • Fax:
Mailing address:
  • Phone: 310-614-0575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: