Healthcare Provider Details

I. General information

NPI: 1144091760
Provider Name (Legal Business Name): BOLARINWA ADEOYE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 RIDGE RD
LANSING IL
60438-2161
US

IV. Provider business mailing address

2521 RIDGE RD
LANSING IL
60438-2161
US

V. Phone/Fax

Practice location:
  • Phone: 708-858-2939
  • Fax: 708-889-6317
Mailing address:
  • Phone: 708-858-2939
  • Fax: 708-889-6317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041384097
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: