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General NPI Number Information
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NPI Number | 1811041668
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Entity Type | Organization
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Legal Business Name | GOODLIFE MEDICAL CENTER, PLLC
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 09/20/2007
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Provider Practice Location Address
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Address Line | 756 RIDGE LAKE BLVD SUITE 228
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City | MEMPHIS
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State | TN
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Zip | 38120-9420
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Country | US
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Telephone | 901-685-1994
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Fax | 901-685-1997
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Provider Business Mailing Address
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Address Line | PO BOX 172126
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City | MEMPHIS
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State | TN
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Zip | 38187-2126
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Country | US
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Telephone | 901-685-1994
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Fax | 901-685-1997
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Authorized Official
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Title or Position | PRESIDENT
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Name | OLUGBENGA ADEBANJO
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Credential | MD
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Telephone | 901-685-1994
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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 | 37598
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License Number State | TN
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