Provider Demographics
NPI:1598883738
Name:FATADE HEALTH AND MEDICAL CENTER
Entity Type:Organization
Organization Name:FATADE HEALTH AND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AYOKUNLE
Authorized Official - Middle Name:OMOTADE
Authorized Official - Last Name:FATADE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-627-8070
Mailing Address - Street 1:255 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BASSETT
Mailing Address - State:VA
Mailing Address - Zip Code:24055-4299
Mailing Address - Country:US
Mailing Address - Phone:276-627-8070
Mailing Address - Fax:276-627-8069
Practice Address - Street 1:255 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BASSETT
Practice Address - State:VA
Practice Address - Zip Code:24055-4299
Practice Address - Country:US
Practice Address - Phone:276-627-8070
Practice Address - Fax:276-627-8069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201991261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center