1679746713 NPI number — OLUSEGUN Z. SALAKO M.D. INC

Table of content: (NPI 1679746713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679746713 NPI number — OLUSEGUN Z. SALAKO M.D. INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLUSEGUN Z. SALAKO M.D. INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMFORT MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
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:
1679746713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 W ANAHEIM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90744-4418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-816-3111
Provider Business Mailing Address Fax Number:
310-816-3116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 W ANAHEIM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90744-4418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-816-3111
Provider Business Practice Location Address Fax Number:
310-816-3116
Provider Enumeration Date:
04/09/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MGBOJIRIKWE
Authorized Official First Name:
THECLA
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
PEDIATRIC SPECIALIST/MEDICAL DIRECT
Authorized Official Telephone Number:
562-218-6264

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G54804 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: A83572 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: G67118 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0098551 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G54804 . This is a "MEDICARE SOUTHERN CA." identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".