Healthcare Provider Details

I. General information

NPI: 1457226276
Provider Name (Legal Business Name): MICHAEL SOLEDAYO FAGBAMIYE CEO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

6025 PEREGRINE BLVD
INDIANAPOLIS IN
46228-1504
US

IV. Provider business mailing address

6025 PEREGRINE BLVD
INDIANAPOLIS IN
46228-1504
US

V. Phone/Fax

Practice location:
  • Phone: 317-652-6420
  • Fax:
Mailing address:
  • Phone: 317-652-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number25-018973-1
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number25-018973-1
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: