Healthcare Provider Details

I. General information

NPI: 1114437894
Provider Name (Legal Business Name): RALUCHUKWU OKONKWO INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 38TH STREET
ISLIP NY
11751
US

IV. Provider business mailing address

59 38TH ST
ISLIP NY
11751-1101
US

V. Phone/Fax

Practice location:
  • Phone: 631-355-6425
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RALUCHUKWU OKONKWO
Title or Position: CEO
Credential:
Phone: 631-355-6425