1215069638 NPI number — EBUNOLUWA ABIMBOLA ANP

Table of content: EBUNOLUWA ABIMBOLA ANP (NPI 1215069638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215069638 NPI number — EBUNOLUWA ABIMBOLA ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABIMBOLA
Provider First Name:
EBUNOLUWA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215069638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 QUAKER LN
Provider Second Line Business Mailing Address:
STE. 207C
Provider Business Mailing Address City Name:
HIGH POINT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27262-3832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-883-2500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 BOULEVARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGH POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27262-3802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-878-6226
Provider Business Practice Location Address Fax Number:
336-878-6272
Provider Enumeration Date:
03/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  900238 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)