Provider Demographics
NPI:1033667118
Name:EKIBOLAJI, A RICHARD
Entity Type:Individual
Prefix:
First Name:A
Middle Name:RICHARD
Last Name:EKIBOLAJI
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 1:2550 RYAN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-5883
Mailing Address - Country:US
Mailing Address - Phone:281-217-5277
Mailing Address - Fax:
Practice Address - Street 1:2550 RYAN ST
Practice Address - Street 2:SUITE B
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-5883
Practice Address - Country:US
Practice Address - Phone:281-217-5277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker