Provider Demographics
NPI:1295221711
Name:VERDURE EXCLUSIVE PA
Entity Type:Organization
Organization Name:VERDURE EXCLUSIVE PA
Other - Org Name:ANGELIC LIFT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINUADE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUSEGUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-855-8633
Mailing Address - Street 1:4645 CLYDE MORRIS BLVD STE 404
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-3005
Mailing Address - Country:US
Mailing Address - Phone:386-855-8633
Mailing Address - Fax:855-857-5810
Practice Address - Street 1:4645 CLYDE MORRIS BLVD STE 404
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-3005
Practice Address - Country:US
Practice Address - Phone:386-855-8633
Practice Address - Fax:855-857-5810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty