Healthcare Provider Details

I. General information

NPI: 1598952392
Provider Name (Legal Business Name): MRS. KIKELOMO OGUNDIRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIKELOMO BALOGUN MSED

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MONT AVE
DIX HILLS NY
11746-6836
US

IV. Provider business mailing address

10 MONT AVE
DIX HILLS NY
11746-6836
US

V. Phone/Fax

Practice location:
  • Phone: 631-807-2763
  • Fax: 631-807-2763
Mailing address:
  • Phone: 631-807-2763
  • Fax: 631-807-2763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: