Healthcare Provider Details

I. General information

NPI: 1770269094
Provider Name (Legal Business Name): EUREKA NGOIE KUKULA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2759 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20032-2646
US

IV. Provider business mailing address

650 REALM CT W
ODENTON MD
21113-1559
US

V. Phone/Fax

Practice location:
  • Phone: 202-563-7632
  • Fax:
Mailing address:
  • Phone: 213-461-3568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: