Provider Demographics
NPI:1437283439
Name:FULLAH, OMARU KEKETOMA
Entity Type:Individual
Prefix:
First Name:OMARU
Middle Name:KEKETOMA
Last Name:FULLAH
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 1:8730 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-4830
Mailing Address - Country:US
Mailing Address - Phone:323-752-3026
Mailing Address - Fax:
Practice Address - Street 1:8730 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-4830
Practice Address - Country:US
Practice Address - Phone:323-751-3026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01605808Medicare UPIN