Healthcare Provider Details

I. General information

NPI: 1588016752
Provider Name (Legal Business Name): OKOLOCHA MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 GRANT ST
GARY IN
46404-3060
US

IV. Provider business mailing address

2054 GRANT ST
GARY IN
46404-3060
US

V. Phone/Fax

Practice location:
  • Phone: 219-949-7540
  • Fax: 219-949-7545
Mailing address:
  • Phone: 219-949-7540
  • Fax: 219-949-7545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004976
License Number StateIN

VIII. Authorized Official

Name: PAUL OKOLOCHA
Title or Position: OWNER
Credential: MD
Phone: 219-949-7540