Basic Information
| Provider Information | |||||||||
| NPI: | 1871622761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IHENACHO | ||||||||
| FirstName: | AGATHA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EZEKA | ||||||||
| OtherFirstName: | AGATHA | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6381 BLACKBERRY CT | ||||||||
| Address2: | |||||||||
| City: | GILROY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950203424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088489802 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 455 SILICON VALLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082849000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT31594 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.