Provider Demographics
NPI:1518515485
Name:OKOLI, KENECHI OMAR
Entity Type:Individual
Prefix:
First Name:KENECHI
Middle Name:OMAR
Last Name:OKOLI
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 1:9623 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-3222
Mailing Address - Country:US
Mailing Address - Phone:310-897-9392
Mailing Address - Fax:
Practice Address - Street 1:12440 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3177
Practice Address - Country:US
Practice Address - Phone:800-854-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator