MEDICARE: BOLANLE ODEJIDE RRT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	227900000X	Registered Respiratory Therapist	30008466A	IN

General Provider Information

NPI Number	:	1376957696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BOLANLE ODEJIDE RRT

Provider Business Mailing Address
First Line	:	4247 VILLAGE TRACE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-6229
Country	:	US
Telephone Number	:	317-366-7583
Fax Number	:

Provider Business Practice Location Address
First Line	:	4247 VILLAGE TRACE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-6229
Country	:	US
Telephone Number	:	317-366-7583
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2014
Last Update Date	:	06/14/2014

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Directions to “ BOLANLE ODEJIDE RRT” Practice Location

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