Healthcare Provider Details

I. General information

NPI: 1114553146
Provider Name (Legal Business Name): BASIL O IKE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2020
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

200 S MANCHESTER AVE STE 835
ORANGE CA
92868-3213
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax: 800-465-3203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A19702
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: