Healthcare Provider Details

I. General information

NPI: 1366905283
Provider Name (Legal Business Name): MICHELLE OKOREEH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E GILBERT ST
SAN BERNARDINO CA
92415-0928
US

IV. Provider business mailing address

820 E GILBERT ST
SAN BERNARDINO CA
92415-0928
US

V. Phone/Fax

Practice location:
  • Phone: 909-387-7607
  • Fax:
Mailing address:
  • Phone: 909-387-7607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA179618
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberA179618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: