Provider Demographics
NPI:1447549407
Name:IKE, INNOCENT KEN
Entity type:Individual
Prefix:
First Name:INNOCENT
Middle Name:KEN
Last Name:IKE
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 1:63 RIVERCOACH LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-5545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:63 RIVERCOACH LN
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-5545
Practice Address - Country:US
Practice Address - Phone:832-359-7755
Practice Address - Fax:281-565-5705
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker