Healthcare Provider Details

I. General information

NPI: 1508623281
Provider Name (Legal Business Name): CHUKWUMA OKONKWO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 09/08/2024
Certification Date: 09/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 WILSHIRE BLVD STE PO4
LOS ANGELES CA
90010-2707
US

IV. Provider business mailing address

2324 JULIET ST
LOS ANGELES CA
90007-1517
US

V. Phone/Fax

Practice location:
  • Phone: 323-872-7011
  • Fax:
Mailing address:
  • Phone: 323-872-7011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number3858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: