Healthcare Provider Details

I. General information

NPI: 1295454718
Provider Name (Legal Business Name): OLUWATOMIWA OBADARE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

854 TECHNOLOGY WAY
LIBERTYVILLE IL
60048-5350
US

IV. Provider business mailing address

854 TECHNOLOGY WAY
LIBERTYVILLE IL
60048-5350
US

V. Phone/Fax

Practice location:
  • Phone: 847-816-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number22218786
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: