Healthcare Provider Details

I. General information

NPI: 1407611833
Provider Name (Legal Business Name): ABDULRAHMAN BOLAJI OWOLABI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10811 CLODINE RD # A
RICHMOND TX
77407-9503
US

IV. Provider business mailing address

10811 CLODINE RD # A
RICHMOND TX
77407-9503
US

V. Phone/Fax

Practice location:
  • Phone: 866-230-5771
  • Fax:
Mailing address:
  • Phone: 866-230-5771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number05468213
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: