Healthcare Provider Details

I. General information

NPI: 1962903435
Provider Name (Legal Business Name): PIUS OLISADEBE OKONKWO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11851 HIDEOUT TRL
EULESS TX
76040-1103
US

IV. Provider business mailing address

11851 HIDEOUT TRL
EULESS TX
76040-1103
US

V. Phone/Fax

Practice location:
  • Phone: 214-909-1405
  • Fax:
Mailing address:
  • Phone: 214-909-1405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SH0200X
TaxonomyHome Health Clinical Nurse Specialist
License Number222587
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: