Healthcare Provider Details

I. General information

NPI: 1417743527
Provider Name (Legal Business Name): ADEMOLA OSUNDEKO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N MAIN AVE
LOVINGTON NM
88260-2813
US

IV. Provider business mailing address

2388 FOREST HILLS DR
HARRISBURG PA
17112-1088
US

V. Phone/Fax

Practice location:
  • Phone: 575-396-1985
  • Fax: 575-396-2152
Mailing address:
  • Phone: 717-919-3160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: