Healthcare Provider Details

I. General information

NPI: 1518515485
Provider Name (Legal Business Name): KENECHI OMAR OKOLI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12440 IMPERIAL HWY
NORWALK CA
90650-3177
US

IV. Provider business mailing address

9623 S 2ND AVE
INGLEWOOD CA
90305-3222
US

V. Phone/Fax

Practice location:
  • Phone: 800-854-7771
  • Fax:
Mailing address:
  • Phone: 310-897-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: