=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811362908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAFTER PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2015
-----------------------------------------------------
Last Update Date | 07/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 MUNZER ST SUITE C
-----------------------------------------------------
City | SHAFTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-364-5244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 22694
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93390-2694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-364-5244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. AYODEJI ADETAYO AYENI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 661-364-5244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------