Healthcare Provider Details

I. General information

NPI: 1205668563
Provider Name (Legal Business Name): MOSES THUKU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7673 CHAPPELLE WAY
ELK GROVE CA
95757-1688
US

IV. Provider business mailing address

7673 CHAPPELLE WAY
ELK GROVE CA
95757-1688
US

V. Phone/Fax

Practice location:
  • Phone: 443-710-3011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberR203682
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95375209
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR203682
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number95375209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: