Healthcare Provider Details

I. General information

NPI: 1386424075
Provider Name (Legal Business Name): KINGSLEY OKON BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 MAGNOLIA AVE
LOS ANGELES CA
90007-1220
US

IV. Provider business mailing address

1910 MAGNOLIA AVE
LOS ANGELES CA
90007-1220
US

V. Phone/Fax

Practice location:
  • Phone: 213-342-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: