Healthcare Provider Details

I. General information

NPI: 1619099090
Provider Name (Legal Business Name): MUCHANETA MADUKE OTR, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 JACKSON DR STE 110
LA MESA CA
91942-3012
US

IV. Provider business mailing address

5360 JACKSON DR STE 110
LA MESA CA
91942-3012
US

V. Phone/Fax

Practice location:
  • Phone: 619-667-7000
  • Fax: 619-667-4315
Mailing address:
  • Phone: 619-667-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number4565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: