Healthcare Provider Details

I. General information

NPI: 1699126326
Provider Name (Legal Business Name): JAMES A FAGBODUN ADMINISTRATOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 07/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10648 LUCAYA DR
TAMPA FL
33647-3530
US

IV. Provider business mailing address

10648 LUCAYA DR
TAMPA FL
33647-3530
US

V. Phone/Fax

Practice location:
  • Phone: 813-230-7628
  • Fax: 813-991-9749
Mailing address:
  • Phone: 813-230-7628
  • Fax: 813-991-9749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: