Healthcare Provider Details

I. General information

NPI: 1962646174
Provider Name (Legal Business Name): MR. ACHO JOHNSON OGBOENYIYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 05/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10515 SOUTHWEST FWY SUITE D 103
HOUSTON TX
77074-1127
US

IV. Provider business mailing address

10515 SOUTHWEST FWY SUIT D 103
HOUSTON TX
77074-1127
US

V. Phone/Fax

Practice location:
  • Phone: 713-777-1405
  • Fax: 713-777-1420
Mailing address:
  • Phone: 713-777-1405
  • Fax: 713-777-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1000040
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: