Provider Demographics
NPI:1376721571
Name:FAVOUS THERAPY INC
Entity Type:Organization
Organization Name:FAVOUS THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLUMIDE
Authorized Official - Middle Name:OLAYODE
Authorized Official - Last Name:OGUNJUYIGBE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:202-498-0484
Mailing Address - Street 1:2909 EAGLES NEST DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3905
Mailing Address - Country:US
Mailing Address - Phone:202-498-0484
Mailing Address - Fax:301-805-0634
Practice Address - Street 1:2909 EAGLES NEST DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3905
Practice Address - Country:US
Practice Address - Phone:202-498-0484
Practice Address - Fax:301-805-0634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG02214Medicare PIN