Provider Demographics
NPI:1336137678
Name:MODUPEOLA ADEDEJI
Entity Type:Organization
Organization Name:MODUPEOLA ADEDEJI
Other - Org Name:LA PAZ COMMUNITY HEALTH CARE CENTER, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ADEDIRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEDEJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-697-5700
Mailing Address - Street 1:530 SAN PEDRO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5006
Mailing Address - Country:US
Mailing Address - Phone:210-697-5700
Mailing Address - Fax:210-558-9032
Practice Address - Street 1:530 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5006
Practice Address - Country:US
Practice Address - Phone:210-697-5700
Practice Address - Fax:210-558-9032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX021375301Medicaid
TX021375301Medicaid