Basic Information
| Provider Information | |||||||||
| NPI: | 1972247971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGOHA | ||||||||
| FirstName: | CHIKADIBIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 TURF RD | ||||||||
| Address2: | |||||||||
| City: | SUFFERN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109013944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185364727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 259 1ST ST | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166638443 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2022 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.