Healthcare Provider Details

I. General information

NPI: 1326822792
Provider Name (Legal Business Name): GODWIN ADJEKUKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WOOD ST
EUREKA CA
95501-4413
US

IV. Provider business mailing address

2252 ASHLEY FALLS LN
SUWANEE GA
30024-2639
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-2990
  • Fax:
Mailing address:
  • Phone: 678-548-1532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95154093
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: