Provider Demographics
NPI:1639711534
Name:IMMACULATE VASCULAR ACCESS CENTER PLLC
Entity Type:Organization
Organization Name:IMMACULATE VASCULAR ACCESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NGOZI
Authorized Official - Middle Name:
Authorized Official - Last Name:OKOBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-837-3293
Mailing Address - Street 1:349 S HELEN MOORE RD APT 6205
Mailing Address - Street 2:
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-9091
Mailing Address - Country:US
Mailing Address - Phone:240-837-3293
Mailing Address - Fax:
Practice Address - Street 1:349 S HELEN MOORE RD APT 6205
Practice Address - Street 2:
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-9091
Practice Address - Country:US
Practice Address - Phone:240-837-3293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty