Healthcare Provider Details

I. General information

NPI: 1225851389
Provider Name (Legal Business Name): SOUTH BAY SKIN AND WOUND CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/06/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 W 4TH ST
LONG BEACH CA
90802-2826
US

IV. Provider business mailing address

445 W 4TH ST
LONG BEACH CA
90802-2826
US

V. Phone/Fax

Practice location:
  • Phone: 888-664-3375
  • Fax:
Mailing address:
  • Phone: 888-664-3375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OLUWAFEMISAYO AKINNAGBE
Title or Position: OWNER
Credential: MD
Phone: 888-664-3375