Provider Demographics
NPI:1033551619
Name:KEME, MOPELOLA BEATRICE
Entity Type:Individual
Prefix:
First Name:MOPELOLA
Middle Name:BEATRICE
Last Name:KEME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOPELOLA
Other - Middle Name:BEATRICE
Other - Last Name:KEME-ADAGUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2080 S E ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2773
Mailing Address - Country:US
Mailing Address - Phone:909-388-9191
Mailing Address - Fax:909-388-9195
Practice Address - Street 1:2080 S E ST
Practice Address - Street 2:STE. 100
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2773
Practice Address - Country:US
Practice Address - Phone:909-388-9191
Practice Address - Fax:909-388-9195
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA493927163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124100383Medicaid