Healthcare Provider Details

I. General information

NPI: 1124943592
Provider Name (Legal Business Name): MR. CELESTINE FOMEZA FOTECK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MRS. IVOTA ESEMU NKIE FOTECK

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 N TOBEN CT
BEL AIRE KS
67226-8846
US

IV. Provider business mailing address

5353 N TOBEN CT
BEL AIRE KS
67226-8846
US

V. Phone/Fax

Practice location:
  • Phone: 316-932-3615
  • Fax:
Mailing address:
  • Phone: 316-932-3615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberB087134
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: