Healthcare Provider Details

I. General information

NPI: 1124550678
Provider Name (Legal Business Name): KAYODE BOLAJI OGUNSOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7538 N RIDGE BLVD APT 3WEST
CHICAGO IL
60645-1115
US

IV. Provider business mailing address

7538 N RIDGE BLVD APT 3WEST
CHICAGO IL
60645-1115
US

V. Phone/Fax

Practice location:
  • Phone: 773-671-2324
  • Fax: 773-856-5666
Mailing address:
  • Phone: 773-671-2324
  • Fax: 773-856-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: