MEDICARE: OFOHA, M.D. CLINIC, LLC.

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	261Q00000X	Clinic/Center	1046	VI

General Provider Information

NPI Number	:	1194029306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OFOHA, M.D. CLINIC, LLC.

Provider Business Mailing Address
First Line	:	PO BOX 12199
Second Line	:
City	:	ST THOMAS
State	:	VI
Zip	:	00801-5199
Country	:	US
Telephone Number	:	340-714-5800
Fax Number	:

Provider Business Practice Location Address
First Line	:	9202 VITRACO PARK
Second Line	:	SUITE 13
City	:	ST THOMAS
State	:	VI
Zip	:	00802
Country	:	US
Telephone Number	:	340-714-5800
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KENNETH O OFOHA
Credential	:	M.D.
Telephone Number	:	340-714-5800

Provider Enumeration Date	:	01/03/2011
Last Update Date	:	01/03/2011

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