Provider Demographics
NPI:1528331725
Name:OMODEHINDE, SONNY/ (N/A)
Entity type:Individual
Prefix:MR
First Name:SONNY/
Middle Name:
Last Name:OMODEHINDE
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10188 HASKINS ST
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66215-1858
Mailing Address - Country:US
Mailing Address - Phone:913-908-7916
Mailing Address - Fax:
Practice Address - Street 1:10188 HASKINS ST
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-1858
Practice Address - Country:US
Practice Address - Phone:913-908-7916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSA046184251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health