Healthcare Provider Details

I. General information

NPI: 1053959411
Provider Name (Legal Business Name): NUGAHEALTH PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3565 ELLICOTT MILLS DR STE B2
ELLICOTT CITY MD
21043-4549
US

IV. Provider business mailing address

3565 ELLICOTT MILLS DR STE B2
ELLICOTT CITY MD
21043-4549
US

V. Phone/Fax

Practice location:
  • Phone: 443-282-3413
  • Fax: 443-276-7475
Mailing address:
  • Phone: 443-282-3413
  • Fax: 443-276-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OMOBOLANLE M ADENUGA
Title or Position: CRNP-F
Credential:
Phone: 443-282-3413