Provider Demographics
NPI:1154166619
Name:SOFOLAHAN, IBRAHIM ADEWALE (OWNER)
Entity type:Individual
Prefix:MR
First Name:IBRAHIM
Middle Name:ADEWALE
Last Name:SOFOLAHAN
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 INDEPENDENCE WAY APT 10313
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02921-2046
Mailing Address - Country:US
Mailing Address - Phone:228-313-9209
Mailing Address - Fax:
Practice Address - Street 1:75 INDEPENDENCE WAY APT 10313
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02921-2046
Practice Address - Country:US
Practice Address - Phone:228-313-9209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPMV-578343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)