Healthcare Provider Details

I. General information

NPI: 1699398750
Provider Name (Legal Business Name): GRACE CHIGOZIE OTUM RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2020
Last Update Date: 05/24/2020
Certification Date: 05/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 KATY GAP RD APT 21106
KATY TX
77494-7720
US

IV. Provider business mailing address

8787 WOODWAY DR APT 1107
HOUSTON TX
77063-2424
US

V. Phone/Fax

Practice location:
  • Phone: 205-790-3916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT85863
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: