Provider Demographics
NPI:1093464919
Name:AMAECHI, EBEREGBULAM
Entity Type:Individual
Prefix:
First Name:EBEREGBULAM
Middle Name:
Last Name:AMAECHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3132 S CANYON ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8378
Mailing Address - Country:US
Mailing Address - Phone:208-440-4411
Mailing Address - Fax:
Practice Address - Street 1:3132 S CANYON ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8378
Practice Address - Country:US
Practice Address - Phone:208-440-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0003766Medicaid