Provider Demographics
NPI:1518222454
Name:ADETOLA, MODUPE VICTORIA
Entity Type:Individual
Prefix:
First Name:MODUPE
Middle Name:VICTORIA
Last Name:ADETOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11326 CHERRY HILL RD UNIT 104
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3719
Mailing Address - Country:US
Mailing Address - Phone:240-470-9192
Mailing Address - Fax:
Practice Address - Street 1:11326 CHERRY HILL RD UNIT 104
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-3719
Practice Address - Country:US
Practice Address - Phone:240-470-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide