Healthcare Provider Details

I. General information

NPI: 1306200696
Provider Name (Legal Business Name): MOSES KOLAWOLE OLOFIN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 RICHIE AVE APT#3
LIMA OH
45801-5923
US

IV. Provider business mailing address

841 RICHIE AVE APT#3
LIMA OH
45801-5923
US

V. Phone/Fax

Practice location:
  • Phone: 419-371-6502
  • Fax:
Mailing address:
  • Phone: 419-371-6502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number425332
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: