Provider Demographics
NPI:1699126326
Name:FAGBODUN, JAMES A (ADMINISTRATOR)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:A
Last Name:FAGBODUN
Suffix:
Gender:M
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10648 LUCAYA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3530
Mailing Address - Country:US
Mailing Address - Phone:813-230-7628
Mailing Address - Fax:813-991-9749
Practice Address - Street 1:10648 LUCAYA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3530
Practice Address - Country:US
Practice Address - Phone:813-230-7628
Practice Address - Fax:813-991-9749
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility