Healthcare Provider Details

I. General information

NPI: 1508544917
Provider Name (Legal Business Name): SHOLA OGUNDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 TRADEWIND PASS DR
MISSOURI CITY TX
77459-2665
US

IV. Provider business mailing address

2410 TRADEWIND PASS DR
MISSOURI CITY TX
77459-2665
US

V. Phone/Fax

Practice location:
  • Phone: 404-790-3420
  • Fax:
Mailing address:
  • Phone: 404-790-3420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number059630569
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: