Healthcare Provider Details

I. General information

NPI: 1528816097
Provider Name (Legal Business Name): EJERE OKORIE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 S WILLOW AVE
RIALTO CA
92376-6934
US

IV. Provider business mailing address

25774 MESA CT
SAN BERNARDINO CA
92404-3074
US

V. Phone/Fax

Practice location:
  • Phone: 909-820-8150
  • Fax:
Mailing address:
  • Phone: 909-278-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95221316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: