Healthcare Provider Details

I. General information

NPI: 1518257492
Provider Name (Legal Business Name): VICTOR IKEMEFULA UKONU HOME HEALTH CARE ADM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 NW 64ST
OKLAHOMA OK
73116
US

IV. Provider business mailing address

P.O.BOX 720850
OKLAHOMA CITY OK
73172-1610
US

V. Phone/Fax

Practice location:
  • Phone: 405-602-4746
  • Fax:
Mailing address:
  • Phone: 405-602-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number37D674350807
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: