Healthcare Provider Details

I. General information

NPI: 1821576323
Provider Name (Legal Business Name): MR. BRYAN OKOLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1879 SANFORD ST
PHILADELPHIA PA
19116-3845
US

IV. Provider business mailing address

1879 SANFORD ST
PHILADELPHIA PA
19116-3845
US

V. Phone/Fax

Practice location:
  • Phone: 267-265-7292
  • Fax:
Mailing address:
  • Phone: 267-265-7292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: