Healthcare Provider Details

I. General information

NPI: 1235847526
Provider Name (Legal Business Name): IBUKUN ADEDOKUN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6439 GARNERS FERRY RD
COLUMBIA SC
29209-1638
US

IV. Provider business mailing address

460 CURLEW CIR
SUMTER SC
29150-5344
US

V. Phone/Fax

Practice location:
  • Phone: 803-776-4000
  • Fax:
Mailing address:
  • Phone: 858-736-7314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: