=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619307162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IBRAHIM OLASUNKANMI SHOBALOJU
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2013
-----------------------------------------------------
Last Update Date | 11/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 BRUCE PL SE APT 401
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20020-2950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-704-1628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 BRUCE PL SE APT 401
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20020-2950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-704-1628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | HHA9601
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------