Healthcare Provider Details

I. General information

NPI: 1902385966
Provider Name (Legal Business Name): BECKY JUSTINA EKHOMU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5726 W HAUSMAN RD
SAN ANTONIO TX
78249-1650
US

IV. Provider business mailing address

4041 MEDICAL DR APT 1302
SAN ANTONIO TX
78229-2122
US

V. Phone/Fax

Practice location:
  • Phone: 210-349-7030
  • Fax: 210-349-0097
Mailing address:
  • Phone: 210-505-0545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number774035
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: