Basic Information
| Provider Information | |||||||||
| NPI: | 1639409790 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ONYEKURU | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | U | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2521 GREENFIELD DR | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730126527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059967914 | ||||||||
| FaxNumber: | 4055281802 | ||||||||
| Practice Location | |||||||||
| Address1: | 2521 GREENFIELD DR | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730126527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059967914 | ||||||||
| FaxNumber: | 4055281802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2010 | ||||||||
| LastUpdateDate: | 01/12/2010 | ||||||||
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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 | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 200120060A | 05 | OK | MEDICAID |