Healthcare Provider Details

I. General information

NPI: 1396384277
Provider Name (Legal Business Name): KELLY OKOROCHA ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2019
Last Update Date: 12/25/2019
Certification Date: 12/25/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 MAPLEWOOD DR
SULPHUR LA
70663-6302
US

IV. Provider business mailing address

3546 TAYLOR ST
LAKE CHARLES LA
70607-2110
US

V. Phone/Fax

Practice location:
  • Phone: 337-214-0029
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: