Healthcare Provider Details

I. General information

NPI: 1275916306
Provider Name (Legal Business Name): VENUS EFEBO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 MISSILE RD
WICHITA FALLS TX
76306-1321
US

IV. Provider business mailing address

2511 MISSILE RD
WICHITA FALLS TX
76306-1321
US

V. Phone/Fax

Practice location:
  • Phone: 716-830-8024
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: