Healthcare Provider Details

I. General information

NPI: 1407494735
Provider Name (Legal Business Name): ADEKUNLE SAMSON ADEGBITE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4960 ARLINGTON AVE STE B
RIVERSIDE CA
92504-2738
US

IV. Provider business mailing address

231 E ALESSANDRO BLVD # A805
RIVERSIDE CA
92508-5084
US

V. Phone/Fax

Practice location:
  • Phone: 951-341-8930
  • Fax: 951-341-8932
Mailing address:
  • Phone: 951-341-8935
  • Fax: 951-341-8932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP95013014
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95013014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: