Healthcare Provider Details

I. General information

NPI: 1447820899
Provider Name (Legal Business Name): KELECHI EBO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CAMBRIC PL
ROCKY HILL CT
06067-3256
US

IV. Provider business mailing address

49 PUTNAM BLVD # 1010
GLASTONBURY CT
06033-1079
US

V. Phone/Fax

Practice location:
  • Phone: 186-020-0262
  • Fax:
Mailing address:
  • Phone: 860-200-2625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: