Healthcare Provider Details

I. General information

NPI: 1073159935
Provider Name (Legal Business Name): ADEKUMBI OLUFUNSO OGUNDELE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 OLD CROW CANYON RD STE 195
SAN RAMON CA
94583-1240
US

IV. Provider business mailing address

2411 OLD CROW CANYON RD STE 160
SAN RAMON CA
94583-1200
US

V. Phone/Fax

Practice location:
  • Phone: 925-954-5292
  • Fax:
Mailing address:
  • Phone: 925-208-9250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number95072316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: