Provider Demographics
NPI:1558143065
Name:BANJO, OLUGBENGA OLALEKAN
Entity Type:Individual
Prefix:MR
First Name:OLUGBENGA
Middle Name:OLALEKAN
Last Name:BANJO
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 1:1160 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:ST PAUL PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55071-1344
Mailing Address - Country:US
Mailing Address - Phone:651-210-9638
Mailing Address - Fax:
Practice Address - Street 1:1160 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:ST PAUL PARK
Practice Address - State:MN
Practice Address - Zip Code:55071-1344
Practice Address - Country:US
Practice Address - Phone:651-210-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN413980310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility