Healthcare Provider Details

I. General information

NPI: 1720835788
Provider Name (Legal Business Name): TAI ODUSAMI PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25630 FELICIA AVE
MENIFEE CA
92586-2376
US

IV. Provider business mailing address

25630 FELICIA AVE
MENIFEE CA
92586-2376
US

V. Phone/Fax

Practice location:
  • Phone: 951-772-6402
  • Fax:
Mailing address:
  • Phone: 951-772-6402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: