Provider Demographics
NPI:1952153553
Name:TECHIE, GODWIN
Entity Type:Individual
Prefix:
First Name:GODWIN
Middle Name:
Last Name:TECHIE
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 1:2433 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3646
Mailing Address - Country:US
Mailing Address - Phone:309-218-6821
Mailing Address - Fax:
Practice Address - Street 1:2433 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-3646
Practice Address - Country:US
Practice Address - Phone:309-218-6821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20028575170172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver