MEDICARE: MRS. MODUPE MUYIBATU AJAYI I

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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1427772771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MODUPE MUYIBATU AJAYI I

Provider Business Mailing Address
First Line	:	5939 VEGAS DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2422
Country	:	US
Telephone Number	:	702-241-8755
Fax Number	:

Provider Business Practice Location Address
First Line	:	5939 VEGAS DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2422
Country	:	US
Telephone Number	:	702-241-8755
Fax Number	:

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

Provider Enumeration Date	:	09/30/2022
Last Update Date	:	09/30/2022

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