=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649522335
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. LOUIS IKECHUKWU NWOKEOCHA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2012
-----------------------------------------------------
Last Update Date | 10/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 580 GRANT AVE
-----------------------------------------------------
City | NORTH BALDWIN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11510-1329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-400-5373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 580 GRANT AVE
-----------------------------------------------------
City | NORTH BALDWIN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11510-1329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-400-5373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332BD1200X
-----------------------------------------------------
Taxonomy Name | Dialysis Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 332BN1400X
-----------------------------------------------------
Taxonomy Name | Nursing Facility Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------