Healthcare Provider Details

I. General information

NPI: 1487809554
Provider Name (Legal Business Name): SAMMY OGUNLEYE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 N ARROWHEAD AVE SUITE 100
SAN BERNARDINO CA
92401-1144
US

IV. Provider business mailing address

688 N ARROWHEAD AVE SUITE 100
SAN BERNARDINO CA
92401-1144
US

V. Phone/Fax

Practice location:
  • Phone: 909-885-2415
  • Fax: 909-885-2460
Mailing address:
  • Phone: 909-885-2415
  • Fax: 909-885-2460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number46256
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: