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General NPI Number Information
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NPI Number | 1295221711
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Entity Type | Organization
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Legal Business Name | VERDURE EXCLUSIVE PA
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Dates
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Enumeration Date | 07/09/2018
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Last Update Date | 12/13/2022
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Provider Practice Location Address
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Address Line | 4645 CLYDE MORRIS BLVD STE 404
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City | PORT ORANGE
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State | FL
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Zip | 32129-3005
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Country | US
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Telephone | 386-855-8633
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Fax | 855-857-5810
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Provider Business Mailing Address
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Address Line | 4645 CLYDE MORRIS BLVD STE 404
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City | PORT ORANGE
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State | FL
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Zip | 32129-3005
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Country | US
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Telephone | 386-855-8633
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Fax | 855-857-5810
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Authorized Official
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Title or Position | OWNER
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Name | TINUADE OLUSEGUN
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Credential | MD
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Telephone | 386-855-8633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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