=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699029793
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ODOCHI NWAGWU MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2012
-----------------------------------------------------
Last Update Date | 10/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11678 RANCHO RD
-----------------------------------------------------
City | ADELANTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92301-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-246-9555
-----------------------------------------------------
Fax | 760-246-9115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11678 RANCHO RD
-----------------------------------------------------
City | ADELANTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92301-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-246-9555
-----------------------------------------------------
Fax | 760-246-9115
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRICIAN/CEO
-----------------------------------------------------
Name | DR. ODOCHI N. NWAGWU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 760-246-9555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------