MEDICARE: MR. OLUFEMI KOLAWOLE

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	54393	CA

General Provider Information

NPI Number	:	1164712774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OLUFEMI KOLAWOLE

Provider Business Mailing Address
First Line	:	2201 E ANAHEIM ST
Second Line	:	SUITE 101
City	:	LONG BEACH
State	:	CA
Zip	:	90804-3411
Country	:	US
Telephone Number	:	562-434-1000
Fax Number	:	562-434-5050

Provider Business Practice Location Address
First Line	:	2201 E ANAHEIM ST
Second Line	:	SUITE 101
City	:	LONG BEACH
State	:	CA
Zip	:	90804-3411
Country	:	US
Telephone Number	:	562-434-1000
Fax Number	:	562-434-5050

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

Provider Enumeration Date	:	04/15/2011
Last Update Date	:	04/15/2011

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