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General NPI Number Information
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NPI Number | 1982568606
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Entity Type | Individual
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Provider Name | GBENGA OMOTAYO
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Gender | Male
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Dates
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Enumeration Date | 12/16/2025
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Last Update Date | 12/16/2025
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Provider Practice Location Address
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Address Line | 252 BLUE IRIS CT
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City | WINDER
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State | GA
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Zip | 30680-4389
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Country | US
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Telephone | 404-989-7102
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Fax |
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Provider Business Mailing Address
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Address Line | 252 BLUE IRIS CT
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City | WINDER
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State | GA
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Zip | 30680-4389
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Country | US
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Telephone | 404-989-7102
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | PHCP044197
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License Number State | GA
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