Healthcare Provider Details

I. General information

NPI: 1093125668
Provider Name (Legal Business Name): YEJIDE OLUSOLA OLUDARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12014 NEWTON TRL
SAN ANTONIO TX
78253-5696
US

IV. Provider business mailing address

12014 NEWTON TRL
SAN ANTONIO TX
78253-5696
US

V. Phone/Fax

Practice location:
  • Phone: 361-343-0695
  • Fax:
Mailing address:
  • Phone: 361-343-0695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. YEJIDE OLUSOLA OLUDARE
Title or Position: RN-BSN
Credential: DON
Phone: 361-343-0695