Healthcare Provider Details

I. General information

NPI: 1457626848
Provider Name (Legal Business Name): JUSTIN OTIWU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3965 BRADFORD WALK TRL
BUFORD GA
30519-7840
US

IV. Provider business mailing address

3965 BRADFORD WALK TRL
BUFORD GA
30519-7840
US

V. Phone/Fax

Practice location:
  • Phone: 770-355-4114
  • Fax:
Mailing address:
  • Phone: 770-355-4114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number067-R-0704
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: