Healthcare Provider Details

I. General information

NPI: 1437267556
Provider Name (Legal Business Name): ADEYINKA MARK FAGBAMILA B.SC RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20510 FENKELL ST
DETROIT MI
48223-1613
US

IV. Provider business mailing address

26696 ISLEWORTH PT
SOUTHFIELD MI
48034-5670
US

V. Phone/Fax

Practice location:
  • Phone: 313-534-6611
  • Fax:
Mailing address:
  • Phone: 313-492-1946
  • Fax: 248-799-7645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501009139
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: