Provider Demographics
NPI:1811636616
Name:OLUWOLE, SAMUEL OLUKUNLE
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:OLUKUNLE
Last Name:OLUWOLE
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 1:102 OLIVIA CT
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-4504
Mailing Address - Country:US
Mailing Address - Phone:615-732-3415
Mailing Address - Fax:615-732-8954
Practice Address - Street 1:102 OLIVIA CT
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-4504
Practice Address - Country:US
Practice Address - Phone:615-732-3415
Practice Address - Fax:615-732-8954
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN376J00000X
385H00000X, 251C00000X, 385HR2060X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No385H00000XRespite Care FacilityRespite Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN86-3482472Other86-3482472