Healthcare Provider Details

I. General information

NPI: 1497628762
Provider Name (Legal Business Name): MR. OLUWA ODUMOSU JR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 6TH AVE STE 400
DES MOINES IA
50309-4108
US

IV. Provider business mailing address

84 SCENIC DR
WEST WARWICK RI
02893-5499
US

V. Phone/Fax

Practice location:
  • Phone: 855-597-1248
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN71422
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: