Provider Demographics
NPI:1063293603
Name:SHA DIABETES CENTER LLC
Entity type:Organization
Organization Name:SHA DIABETES CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TAI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLAJI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MBA/MHCA
Authorized Official - Phone:334-778-7090
Mailing Address - Street 1:172 LUDS WAY,
Mailing Address - Street 2:P. O. BOX 8803
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36304-8803
Mailing Address - Country:US
Mailing Address - Phone:334-778-7090
Mailing Address - Fax:
Practice Address - Street 1:172 LUDS WAY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36304-8803
Practice Address - Country:US
Practice Address - Phone:334-475-0646
Practice Address - Fax:334-888-8445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center