Healthcare Provider Details

I. General information

NPI: 1376958843
Provider Name (Legal Business Name): STELLA ONYEKWELU, OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 BOOTH RD (INSIDE WALMART VISION CENTER)
WARNER ROBINS GA
31088-3422
US

IV. Provider business mailing address

86 WESTCLIFF CIR
WARNER ROBINS GA
31093-8899
US

V. Phone/Fax

Practice location:
  • Phone: 478-918-0636
  • Fax: 478-918-0683
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002814
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT002814
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPT002814
License Number StateGA

VIII. Authorized Official

Name: DR. STELLA ONYEKWELU
Title or Position: DR
Credential: OD
Phone: 618-741-3715