Provider Demographics
NPI:1871890483
Name:ODEDERE, ADEBAYO ADEPOJU (PRESIDENT)
Entity type:Individual
Prefix:
First Name:ADEBAYO
Middle Name:ADEPOJU
Last Name:ODEDERE
Suffix:
Gender:M
Credentials:PRESIDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 LANCEY DR
Mailing Address - Street 2:LANCEY DRIVE
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-8909
Mailing Address - Country:US
Mailing Address - Phone:336-491-9677
Mailing Address - Fax:
Practice Address - Street 1:2006 LANCEY DR
Practice Address - Street 2:LANCEY DRIVE
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-8909
Practice Address - Country:US
Practice Address - Phone:336-491-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27-0097711374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide