Healthcare Provider Details

I. General information

NPI: 1992232144
Provider Name (Legal Business Name): DR. OWORI BWIRE MANG'ENI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 BRAEBURN DR
SALEM VA
24153-7357
US

IV. Provider business mailing address

1802 BRAEBURN DR
SALEM VA
24153-7357
US

V. Phone/Fax

Practice location:
  • Phone: 720-891-8317
  • Fax:
Mailing address:
  • Phone: 720-891-8317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036173178
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101274542
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: