Healthcare Provider Details

I. General information

NPI: 1295293058
Provider Name (Legal Business Name): KALU BEN IROHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6418 SWATNER DR
RALEIGH NC
27612-1963
US

IV. Provider business mailing address

6418 SWATNER DR
RALEIGH NC
27612-1963
US

V. Phone/Fax

Practice location:
  • Phone: 803-937-9023
  • Fax:
Mailing address:
  • Phone: 803-937-9023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number124171
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: