Healthcare Provider Details

I. General information

NPI: 1326621301
Provider Name (Legal Business Name): KWAME OKOREEH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E GILBERT ST
SAN BERNARDINO CA
92415-0928
US

IV. Provider business mailing address

12337 GOODWOOD DR
RANCHO CUCAMONGA CA
91739-2401
US

V. Phone/Fax

Practice location:
  • Phone: 909-387-7200
  • Fax:
Mailing address:
  • Phone: 909-518-1805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number396122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: