MEDICARE: MS. ABIOLA ILEMOBOLA DADA-LAJUMOKE

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	332BC3200X	Customized Equipment (DME)	0100062	TX

General Provider Information

NPI Number	:	1811178171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ABIOLA ILEMOBOLA DADA-LAJUMOKE

Provider Business Mailing Address
First Line	:	2304 OAK LN
Second Line	:	SUITE 224, PARC OAK PLAZA
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-8812
Country	:	US
Telephone Number	:	972-263-3808
Fax Number	:	214-988-1049

Provider Business Practice Location Address
First Line	:	2304 OAK LN
Second Line	:	SUITE 224, PARC OAK PLAZA
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-8812
Country	:	US
Telephone Number	:	972-263-3808
Fax Number	:	214-988-1049

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

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	11/15/2007

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