Healthcare Provider Details

I. General information

NPI: 1700821394
Provider Name (Legal Business Name): MR. TAIWO O BADA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 JONES ST
MARSHVILLE NC
28103-1231
US

IV. Provider business mailing address

PO BOX 237
MARSHVILLE NC
28103-0237
US

V. Phone/Fax

Practice location:
  • Phone: 704-624-0346
  • Fax: 704-624-0356
Mailing address:
  • Phone: 704-624-0346
  • Fax: 704-624-0356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7131
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: