Provider Demographics
NPI:1114514494
Name:BANKOLE, SAMUEL A
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:BANKOLE
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 1:2702 TWIN BRIDGES LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-2773
Mailing Address - Country:US
Mailing Address - Phone:209-482-7114
Mailing Address - Fax:
Practice Address - Street 1:5250 CLAREMONT AVE STE 135
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5700
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician