Healthcare Provider Details

I. General information

NPI: 1558692871
Provider Name (Legal Business Name): EXODUS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 RIEGER DR
MONROE NY
10950-1628
US

IV. Provider business mailing address

PO BOX 4124
MIDDLETOWN NY
10941-8124
US

V. Phone/Fax

Practice location:
  • Phone: 845-341-0211
  • Fax: 845-675-5007
Mailing address:
  • Phone: 845-341-0211
  • Fax: 845-675-5007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. OLANREWAJU O SOMORIN
Title or Position: CEO
Credential: M.D.
Phone: 845-341-0211