Healthcare Provider Details

I. General information

NPI: 1689245961
Provider Name (Legal Business Name): OLUGBENGA AKINWALE OBAJUWONLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 07/07/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4442 AVERY PARK AVE
LAS VEGAS NV
89110-5488
US

IV. Provider business mailing address

4442 AVERY PARK AVE
LAS VEGAS NV
89110-5488
US

V. Phone/Fax

Practice location:
  • Phone: 702-934-0219
  • Fax:
Mailing address:
  • Phone: 702-541-4817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: