Provider Demographics
NPI:1629784137
Name:BRIGHT, OPEOLUWA SAMUEL
Entity Type:Individual
Prefix:
First Name:OPEOLUWA
Middle Name:SAMUEL
Last Name:BRIGHT
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 1:5206 PALMER LN NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3871
Mailing Address - Country:US
Mailing Address - Phone:763-639-2552
Mailing Address - Fax:
Practice Address - Street 1:5019 25TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-5830
Practice Address - Country:US
Practice Address - Phone:763-639-2552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1112646253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency