Healthcare Provider Details

I. General information

NPI: 1780647198
Provider Name (Legal Business Name): CHIDI OJINNAKA LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 W MAIN ST
MANCHESTER IA
52057-1526
US

IV. Provider business mailing address

709 W MAIN ST
MANCHESTER IA
52057-1526
US

V. Phone/Fax

Practice location:
  • Phone: 563-927-7330
  • Fax: 563-927-7409
Mailing address:
  • Phone: 563-927-7330
  • Fax: 563-927-7409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number01197
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: