Provider Demographics
NPI:1790054203
Name:ENEMUO, MADUKA JOSEPH
Entity Type:Individual
Prefix:MR
First Name:MADUKA
Middle Name:JOSEPH
Last Name:ENEMUO
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 1:8728 DUSTY WAGON AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-7232
Mailing Address - Country:US
Mailing Address - Phone:702-449-3634
Mailing Address - Fax:702-228-0506
Practice Address - Street 1:8728 DUSTY WAGON AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7232
Practice Address - Country:US
Practice Address - Phone:702-449-3634
Practice Address - Fax:702-228-0506
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner