Healthcare Provider Details

I. General information

NPI: 1356830491
Provider Name (Legal Business Name): TONY OKAFOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 GUNTOWN RD
ROGERSVILLE TN
37857-3926
US

IV. Provider business mailing address

247 GUNTOWN RD
ROGERSVILLE TN
37857-3926
US

V. Phone/Fax

Practice location:
  • Phone: 423-794-6307
  • Fax:
Mailing address:
  • Phone: 423-794-6307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number107234675
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: