Healthcare Provider Details

I. General information

NPI: 1801640354
Provider Name (Legal Business Name): AYORINDE OWATEMI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 TREMONT ST STE 2
ROXBURY MA
02120-2193
US

IV. Provider business mailing address

1059 TREMONT ST STE 2
BOSTON MA
02120-2193
US

V. Phone/Fax

Practice location:
  • Phone: 857-234-3552
  • Fax: 857-437-5071
Mailing address:
  • Phone: 857-234-3552
  • Fax: 857-437-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: