Provider Demographics
NPI:1750591020
Name:IKANEDEM UMOH
Entity type:Organization
Organization Name:IKANEDEM UMOH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IKANEDEM
Authorized Official - Middle Name:
Authorized Official - Last Name:UMOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-888-4637
Mailing Address - Street 1:10333 HARWIN DR
Mailing Address - Street 2:538
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-1545
Mailing Address - Country:US
Mailing Address - Phone:281-888-4637
Mailing Address - Fax:281-888-6256
Practice Address - Street 1:10333 HARWIN DR
Practice Address - Street 2:538
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-1545
Practice Address - Country:US
Practice Address - Phone:281-888-4637
Practice Address - Fax:281-888-6256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0106049332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195983501Medicaid