Provider Demographics
NPI:1861916637
Name:KAMOTHO, EDWARD KIRERI
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:KIRERI
Last Name:KAMOTHO
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 1:11972 GADWALL DR
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91752-2941
Mailing Address - Country:US
Mailing Address - Phone:714-232-5384
Mailing Address - Fax:
Practice Address - Street 1:11972 GADWALL DR
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91752-2941
Practice Address - Country:US
Practice Address - Phone:714-232-5384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA811329163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse