Basic Information
| Provider Information | |||||||||
| NPI: | 1518515485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OKOLI | ||||||||
| FirstName: | KENECHI | ||||||||
| MiddleName: | OMAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9623 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | INGLEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 903053222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108979392 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12440 IMPERIAL HWY | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906503177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008547771 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2019 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.