Provider Demographics
NPI:1790060440
Name:CHINWENDU CHINWUBA
Entity Type:Organization
Organization Name:CHINWENDU CHINWUBA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHINWENDU
Authorized Official - Middle Name:
Authorized Official - Last Name:CHINWUBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-932-5545
Mailing Address - Street 1:2123 YORKTOWN CT S
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-5061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2123 YORKTOWN CT S
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-5061
Practice Address - Country:US
Practice Address - Phone:832-932-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123456789Medicaid