MEDICARE: THEOPHILUS AGBUKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility		TX

General Provider Information

NPI Number	:	1063664746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THEOPHILUS AGBUKE

Provider Business Mailing Address
First Line	:	PO BOX 781686
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78278-1686
Country	:	US
Telephone Number	:	210-804-1663
Fax Number	:	210-804-1663

Provider Business Practice Location Address
First Line	:	2458 HARRY WURZBACH RD
Second Line	:	#2
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-5002
Country	:	US
Telephone Number	:	210-804-1663
Fax Number	:	210-804-1663

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. THEOPHILUS AGBUKE
Credential	:	R,N.
Telephone Number	:	210-804-1663

Provider Enumeration Date	:	10/14/2008
Last Update Date	:	10/14/2008

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