Healthcare Provider Details

I. General information

NPI: 1467178947
Provider Name (Legal Business Name): TAIWO ODUKOYA ODUTOLA OWNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21880 ORRICK AVE
CARSON CA
90745-3052
US

IV. Provider business mailing address

21880 ORRICK AVE
CARSON CA
90745-3052
US

V. Phone/Fax

Practice location:
  • Phone: 310-927-2119
  • Fax:
Mailing address:
  • Phone: 310-927-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95022131
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: