Provider Demographics
NPI:1700105012
Name:OKOTH, ERIC OCHIENG
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:OCHIENG
Last Name:OKOTH
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 1:1916 VICKERY RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-7610
Mailing Address - Country:US
Mailing Address - Phone:425-289-8514
Mailing Address - Fax:
Practice Address - Street 1:1916 VICKERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-7610
Practice Address - Country:US
Practice Address - Phone:425-289-8514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703103818164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse