Healthcare Provider Details

I. General information

NPI: 1083283634
Provider Name (Legal Business Name): IKECHUKWU CHARLES NWABUOBI NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 06/18/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72047 DINAH SHORE DR STE C4
RANCHO MIRAGE CA
92270-1783
US

IV. Provider business mailing address

409 E THORNTON AVE APT W202
HEMET CA
92543-7657
US

V. Phone/Fax

Practice location:
  • Phone: 760-770-7600
  • Fax:
Mailing address:
  • Phone: 917-605-4369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95017581
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: