Healthcare Provider Details

I. General information

NPI: 1851639330
Provider Name (Legal Business Name): OBI OKOLI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 E. MISSOURI AVE SUITE 12
LAS CRUCES NM
88011-5061
US

IV. Provider business mailing address

2801 E. MISSOURI AVE SUITE 12
LAS CRUCES NM
88011-5061
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-6900
  • Fax: 575-522-8891
Mailing address:
  • Phone: 575-522-6900
  • Fax: 575-522-8891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. OBIEFUNA C OKOLI
Title or Position: CEO
Credential: M.D.
Phone: 575-522-6900