Provider Demographics
NPI:1437991700
Name:OTIENO, BILLY
Entity type:Individual
Prefix:
First Name:BILLY
Middle Name:
Last Name:OTIENO
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 1:2235 MONTEGO DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-4558
Mailing Address - Country:US
Mailing Address - Phone:901-238-5792
Mailing Address - Fax:
Practice Address - Street 1:2235 MONTEGO DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-4558
Practice Address - Country:US
Practice Address - Phone:901-238-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-08
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1344412330172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver