Healthcare Provider Details

I. General information

NPI: 1740404458
Provider Name (Legal Business Name): OGECHUKWU CHARLES OKOLI P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST, NW
ATLANTA GA
30308
US

IV. Provider business mailing address

3333 HOLLY HILL PKWY
ELLENWOOD GA
30294-6566
US

V. Phone/Fax

Practice location:
  • Phone: 404-686-2386
  • Fax:
Mailing address:
  • Phone: 770-765-5586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT008440
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: