MEDICARE: NKEMAKOLAM MAXWELL IROEGBLAM

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		AZ

General Provider Information

NPI Number	:	1750245767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NKEMAKOLAM MAXWELL IROEGBLAM

Provider Business Mailing Address
First Line	:	2509 W BLOOMFIELD RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-2538
Country	:	US
Telephone Number	:	480-577-9460
Fax Number	:

Provider Business Practice Location Address
First Line	:	2509 W BLOOMFIELD RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-2538
Country	:	US
Telephone Number	:	480-577-9460
Fax Number	:

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

Provider Enumeration Date	:	12/13/2025
Last Update Date	:	12/13/2025

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