Healthcare Provider Details

I. General information

NPI: 1629962063
Provider Name (Legal Business Name): HOPE HAVEN MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 SIERRA RIDGE ST
HENDERSON NV
89002-9739
US

IV. Provider business mailing address

990 SIERRA RIDGE ST
HENDERSON NV
89002-9739
US

V. Phone/Fax

Practice location:
  • Phone: 702-934-0219
  • Fax:
Mailing address:
  • Phone: 702-934-0219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OLUWAKEMI TEMITAYO OBAJUWONLO
Title or Position: MD
Credential: MD
Phone: 702-934-0219