MEDICARE: OLUSEGUN OLAYELE III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	46159	CA

General Provider Information

NPI Number	:	1083833404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLUSEGUN OLAYELE III

Provider Business Mailing Address
First Line	:	435 ORANGE SHOW LN
Second Line	:	SUITE 102
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-2015
Country	:	US
Telephone Number	:	909-888-2966
Fax Number	:	909-888-5322

Provider Business Practice Location Address
First Line	:	435 ORANGE SHOW LN
Second Line	:	SUITE 102
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-2015
Country	:	US
Telephone Number	:	909-888-2966
Fax Number	:	909-888-5322

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	03/24/2008

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