Healthcare Provider Details

I. General information

NPI: 1073456505
Provider Name (Legal Business Name): SOLA SEGUN OMOWUMI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 PLEASANT ST STE 100
FALL RIVER MA
02721-3015
US

IV. Provider business mailing address

170 PLEASANT ST STE 100
FALL RIVER MA
02721-3015
US

V. Phone/Fax

Practice location:
  • Phone: 774-294-5722
  • Fax: 774-294-5724
Mailing address:
  • Phone: 774-294-5722
  • Fax: 774-294-5724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: