Healthcare Provider Details

I. General information

NPI: 1306436639
Provider Name (Legal Business Name): MR. AKINBOYENLE SAMSON AKINOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 02/13/2022
Certification Date: 02/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 MAIN ST APT 2
WEST HAVEN CT
06516-4534
US

IV. Provider business mailing address

193 MAIN ST
WEST HAVEN CT
06516-4534
US

V. Phone/Fax

Practice location:
  • Phone: 475-441-0360
  • Fax:
Mailing address:
  • Phone: 475-441-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number012572
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number012572
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: