=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366190365
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHUKWUNYERE OGU
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2022
-----------------------------------------------------
Last Update Date | 03/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 791 STARKE DR
-----------------------------------------------------
City | CERES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95307-7440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-846-5173
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 791 STARKE DR
-----------------------------------------------------
City | CERES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95307-7440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 167G00000X
-----------------------------------------------------
Taxonomy Name | Licensed Psychiatric Technician
-----------------------------------------------------
License Number | 41732
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------