Healthcare Provider Details

I. General information

NPI: 1952071441
Provider Name (Legal Business Name): MR. CHRISTOPHER IKENNA DIKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15740 TURNBERRY ST
MORENO VALLEY CA
92555-4903
US

IV. Provider business mailing address

15740 TURNBERRY ST
MORENO VALLEY CA
92555-4903
US

V. Phone/Fax

Practice location:
  • Phone: 951-363-8449
  • Fax:
Mailing address:
  • Phone: 951-363-8449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1669992053
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: