Healthcare Provider Details

I. General information

NPI: 1306486006
Provider Name (Legal Business Name): OLAWALE LADELOYE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 PACES FERRY RD SE STE 750
ATLANTA GA
30339-4053
US

IV. Provider business mailing address

2727 PACES FERRY RD SE STE 750
ATLANTA GA
30339-4053
US

V. Phone/Fax

Practice location:
  • Phone: 678-464-1822
  • Fax:
Mailing address:
  • Phone: 678-464-1822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number033-R-1947
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: