Provider Demographics
NPI:1598215428
Name:LUCYANNE MORAA OKWOMI
Entity Type:Organization
Organization Name:LUCYANNE MORAA OKWOMI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MALATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:TADAKAMALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-226-7332
Mailing Address - Street 1:6402 W 89TH ST
Mailing Address - Street 2:#4
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-6059
Mailing Address - Country:US
Mailing Address - Phone:913-271-4554
Mailing Address - Fax:
Practice Address - Street 1:6402 W 89TH ST
Practice Address - Street 2:#4
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-6059
Practice Address - Country:US
Practice Address - Phone:913-271-4554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015016093313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility