Healthcare Provider Details

I. General information

NPI: 1194029306
Provider Name (Legal Business Name): OFOHA, M.D. CLINIC, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9202 VITRACO PARK SUITE 13
ST THOMAS VI
00802
US

IV. Provider business mailing address

PO BOX 12199
ST THOMAS VI
00801-5199
US

V. Phone/Fax

Practice location:
  • Phone: 340-714-5800
  • Fax:
Mailing address:
  • Phone: 340-714-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1046
License Number StateVI

VIII. Authorized Official

Name: DR. KENNETH O OFOHA
Title or Position: OWNER
Credential: M.D.
Phone: 340-714-5800