Healthcare Provider Details

I. General information

NPI: 1083255772
Provider Name (Legal Business Name): CALLISTUS C OLISAEKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 CARRIAGE HOUSE CIR APT 3005
ARLINGTON TX
76011-4444
US

IV. Provider business mailing address

1845 CARRIAGE HOUSE CIR # 33005
ARLINGTON TX
76011-4577
US

V. Phone/Fax

Practice location:
  • Phone: 469-410-5315
  • Fax:
Mailing address:
  • Phone: 469-410-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number690631
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: