Provider Demographics
NPI:1407344898
Name:ADEGBOYEGA, ADEWALE RICHARD
Entity type:Individual
Prefix:
First Name:ADEWALE
Middle Name:RICHARD
Last Name:ADEGBOYEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 ROLIDO DR APT 60
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-4325
Mailing Address - Country:US
Mailing Address - Phone:832-451-7945
Mailing Address - Fax:
Practice Address - Street 1:13323 VIA TORRE DE PISA LN
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-4768
Practice Address - Country:US
Practice Address - Phone:936-714-4298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX321756164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse