MEDICARE: EKEI EKPO-ITA MBUKPA OTR

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	163W00000X	Registered Nurse	029649	NY
2	224Z00000X	Occupational Therapy Assistant	006520-1	NY
3	225X00000X	Occupational Therapist	018744	NY
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	56490	WY

General Provider Information

NPI Number	:	1164621165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EKEI EKPO-ITA MBUKPA OTR

Provider Business Mailing Address
First Line	:	461 KIRK RD APT 1A
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-2931
Country	:	US
Telephone Number	:	832-820-7229
Fax Number	:

Provider Business Practice Location Address
First Line	:	2212 SCHICKASAW TRAL #1167
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-2730
Country	:	US
Telephone Number	:	832-820-7229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2007
Last Update Date	:	05/06/2025

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