Provider Demographics
NPI:1427253855
Name:UDOLISA, CHIJIOKE
Entity type:Individual
Prefix:
First Name:CHIJIOKE
Middle Name:
Last Name:UDOLISA
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 1:3519 PATRICK ST
Mailing Address - Street 2:SUITE 262
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-1748
Mailing Address - Country:US
Mailing Address - Phone:337-477-6500
Mailing Address - Fax:337-477-8009
Practice Address - Street 1:3519 PATRICK ST
Practice Address - Street 2:SUITE 262
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-1748
Practice Address - Country:US
Practice Address - Phone:337-477-6500
Practice Address - Fax:337-477-8009
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6879829001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies