Provider Demographics
NPI:1700821394
Name:BADA, TAIWO O
Entity Type:Individual
Prefix:MR
First Name:TAIWO
Middle Name:O
Last Name:BADA
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:PO BOX 237
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-0237
Mailing Address - Country:US
Mailing Address - Phone:704-624-0346
Mailing Address - Fax:704-624-0356
Practice Address - Street 1:507 JONES ST
Practice Address - Street 2:
Practice Address - City:MARSHVILLE
Practice Address - State:NC
Practice Address - Zip Code:28103-1231
Practice Address - Country:US
Practice Address - Phone:704-624-0346
Practice Address - Fax:704-624-0356
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211176Medicaid
NC7211176Medicaid