Healthcare Provider Details

I. General information

NPI: 1740506724
Provider Name (Legal Business Name): CHARLES UDO ENYINNA-OKEIGBO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: UDO CHARLES ENYINNA

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9304 FOREST LN STE 216 S
DALLAS TX
75243-6238
US

IV. Provider business mailing address

9304 FOREST LN STE 216 S
DALLAS TX
75243-6238
US

V. Phone/Fax

Practice location:
  • Phone: 214-295-4324
  • Fax: 214-295-4397
Mailing address:
  • Phone: 214-295-4324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number716453
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number716543
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number716453
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number716453
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number716543
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: