Healthcare Provider Details

I. General information

NPI: 1477831790
Provider Name (Legal Business Name): OLUWASEUN T AWOBUSUYI D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 SARNO RD
MELBOURNE FL
32935-5209
US

IV. Provider business mailing address

1575 SARNO RD
MELBOURNE FL
32935-5209
US

V. Phone/Fax

Practice location:
  • Phone: 321-409-0021
  • Fax: 321-676-8425
Mailing address:
  • Phone: 321-409-0021
  • Fax: 321-676-8425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH 10378
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: