Basic Information
| Provider Information | |||||||||
| NPI: | 1588075865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISIDIENU | ||||||||
| FirstName: | OKAGBUO | ||||||||
| MiddleName: | CONSTANTINE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8810 RIO SAN DIEGO DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921081698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8810 RIO SAN DIEGO DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921081698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2014 | ||||||||
| LastUpdateDate: | 05/08/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | VN277859 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.