Healthcare Provider Details

I. General information

NPI: 1366311557
Provider Name (Legal Business Name): TIMILEYIN ELIJAH OGUNGBAMILA LICENSED VOCATIONAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 11/04/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W EL SEGUNDO BLVD SUITE B
HAWTHORNE CA
90250
US

IV. Provider business mailing address

2501 W EL SEGUNDO BLVD SUITE B
HAWTHORNE CA
90250
US

V. Phone/Fax

Practice location:
  • Phone: 323-754-2816
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number754551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: