Healthcare Provider Details

I. General information

NPI: 1366642266
Provider Name (Legal Business Name): JUDE UCHENNA MGBEKONYE CNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6735 JEFFERSON ST
MERRILLVILLE IN
46410-3408
US

IV. Provider business mailing address

6735 JEFFERSON ST
MERRILLVILLE IN
46410-3408
US

V. Phone/Fax

Practice location:
  • Phone: 219-689-3710
  • Fax:
Mailing address:
  • Phone: 219-689-3710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number44030600684
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: