Provider Demographics
NPI:1164095329
Name:BABATUNDE, BOLAJI GABRIEL (DHA, CPHQ)
Entity Type:Individual
Prefix:DR
First Name:BOLAJI
Middle Name:GABRIEL
Last Name:BABATUNDE
Suffix:
Gender:M
Credentials:DHA, CPHQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9612 E. FOOTHILLL BLVD UNIT 110
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3547
Mailing Address - Country:US
Mailing Address - Phone:909-231-0098
Mailing Address - Fax:
Practice Address - Street 1:9612 E. FOOTHILLL BLVD UNIT 110
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3547
Practice Address - Country:US
Practice Address - Phone:909-231-0098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN648928163WA2000X, 163WH1000X
CA649828163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WH1000XNursing Service ProvidersRegistered NurseHospice