Healthcare Provider Details

I. General information

NPI: 1578734273
Provider Name (Legal Business Name): TAIWO OLUWABUNMI OGUNLEYE RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15785 LIVERNOIS AVE
DETROIT MI
48238-1367
US

IV. Provider business mailing address

7140 PEBBLE PARK DR
WEST BLOOMFIELD MI
48322-3505
US

V. Phone/Fax

Practice location:
  • Phone: 313-934-2623
  • Fax: 313-934-2656
Mailing address:
  • Phone: 248-538-8040
  • Fax: 248-538-8037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501006445
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: