Provider Demographics
NPI:1417372202
Name:AYENI, OMOLAYO
Entity Type:Individual
Prefix:
First Name:OMOLAYO
Middle Name:
Last Name:AYENI
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 1:5105 WOLVERTON CT
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-7673
Mailing Address - Country:US
Mailing Address - Phone:214-755-8104
Mailing Address - Fax:469-270-1515
Practice Address - Street 1:10935 ESTATE LN
Practice Address - Street 2:S-435
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-2316
Practice Address - Country:US
Practice Address - Phone:214-755-8104
Practice Address - Fax:469-270-1515
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX801919617171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator