MEDICARE: ADEBOWALE ALAO ADEDEJI OWNER/CEO

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	261QH0100X	Health Service Clinic/Center	261QH0100X	TX

General Provider Information

NPI Number	:	1295102309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADEBOWALE ALAO ADEDEJI OWNER/CEO

Provider Business Mailing Address
First Line	:	2613 HAWCO DR APT 1822
Second Line	:	2613 HAWCO DR APT 1822
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-7668
Country	:	US
Telephone Number	:	214-705-5047
Fax Number	:

Provider Business Practice Location Address
First Line	:	2613 HAWCO DR APT 1822
Second Line	:	2613 HAWCO DR APT 1822
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-7668
Country	:	US
Telephone Number	:	214-705-5047
Fax Number	:

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

Provider Enumeration Date	:	08/24/2015
Last Update Date	:	08/24/2015

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