=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730230426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AYODEJI O FAMUYIDE M.ED, PT, FAAOMPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3676 HARDING BLVD STE B
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70807-5259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-454-6005
-----------------------------------------------------
Fax | 225-454-6018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 45985
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70895-4985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-248-0085
-----------------------------------------------------
Fax | 225-248-0086
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 03314F
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------