Healthcare Provider Details

I. General information

NPI: 1710314166
Provider Name (Legal Business Name): MGBOKWERE MHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 COVINGTON RIDGE WAY
EL PASO TX
79928-7216
US

IV. Provider business mailing address

1515 HERITAGE DR STE 110
MCKINNEY TX
75069-3379
US

V. Phone/Fax

Practice location:
  • Phone: 972-616-4702
  • Fax:
Mailing address:
  • Phone: 855-860-2109
  • Fax: 855-814-8428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP0856
License Number StateTX

VIII. Authorized Official

Name: CHIOMA J MGBOKWERE
Title or Position: OWNER
Credential: MD
Phone: 862-452-6121