Healthcare Provider Details

I. General information

NPI: 1588016042
Provider Name (Legal Business Name): MR. CHUCKY OKOH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13055 SM 3522
ABILENE TX
79601
US

IV. Provider business mailing address

1112 MELROSE DR
BURLESON TX
76028-7100
US

V. Phone/Fax

Practice location:
  • Phone: 336-624-5049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP130178
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: