Healthcare Provider Details

I. General information

NPI: 1154068567
Provider Name (Legal Business Name): DR. ADEJUMOBI OTEKUNRIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BRIARCLIFF RD NE
ATLANTA GA
30306-2618
US

IV. Provider business mailing address

2107 N DECATUR RD
DECATUR GA
30033-5305
US

V. Phone/Fax

Practice location:
  • Phone: 404-984-3938
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: