Healthcare Provider Details

I. General information

NPI: 1619326956
Provider Name (Legal Business Name): BERTRAM OKOROCHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 10/17/2020
Certification Date: 10/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 DEERPASS DR
CHANNELVIEW TX
77530-3365
US

IV. Provider business mailing address

1037 DEERPASS DR
CHANNELVIEW TX
77530-3365
US

V. Phone/Fax

Practice location:
  • Phone: 281-318-8644
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number233073
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number964293
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: