Healthcare Provider Details

I. General information

NPI: 1700105012
Provider Name (Legal Business Name): ERIC OCHIENG OKOTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 05/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 VICKERY RD
PORTAGE MI
49002-7610
US

IV. Provider business mailing address

1916 VICKERY RD
PORTAGE MI
49002-7610
US

V. Phone/Fax

Practice location:
  • Phone: 425-289-8514
  • Fax:
Mailing address:
  • Phone: 425-289-8514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703103818
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: