Healthcare Provider Details

I. General information

NPI: 1114660271
Provider Name (Legal Business Name): STEPHEN ENYIAKU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/18/2022
Certification Date: 04/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 W STATE ROAD 46
BLOOMINGTON IN
47404-9359
US

IV. Provider business mailing address

5911 W STATE ROAD 46
BLOOMINGTON IN
47404-9359
US

V. Phone/Fax

Practice location:
  • Phone: 812-876-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06005108A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: