Healthcare Provider Details

I. General information

NPI: 1003638107
Provider Name (Legal Business Name): DENIS OKOBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 S STATE ST STE H
SPARTA MI
49345-1593
US

IV. Provider business mailing address

18297 24TH AVE
CONKLIN MI
49403-9777
US

V. Phone/Fax

Practice location:
  • Phone: 616-275-8014
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501303181
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: