Healthcare Provider Details

I. General information

NPI: 1235167974
Provider Name (Legal Business Name): RAIFU ADEWALE OLORUNFEMI P.T., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7380SW 60TH AVE STE 3
OCALA FL
34476-6467
US

IV. Provider business mailing address

7380 SW 60TH AVE STE 3
OCALA FL
34476-6467
US

V. Phone/Fax

Practice location:
  • Phone: 352-840-0004
  • Fax: 352-873-2631
Mailing address:
  • Phone: 352-840-0004
  • Fax: 352-873-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT12870
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: