Healthcare Provider Details

I. General information

NPI: 1679870026
Provider Name (Legal Business Name): OLAJIDE OLUYINKA OKUNROUNMU RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24910 MICHIGAN AVE
DEARBORN MI
48124-1740
US

IV. Provider business mailing address

34600 VAN BORN RD
WAYNE MI
48184-2769
US

V. Phone/Fax

Practice location:
  • Phone: 248-521-6980
  • Fax:
Mailing address:
  • Phone: 248-521-6980
  • Fax: 734-895-9523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501004276
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: