Provider Demographics
NPI:1790471423
Name:OLUGBILE, BOLANLE
Entity Type:Individual
Prefix:
First Name:BOLANLE
Middle Name:
Last Name:OLUGBILE
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 1:105 DANIEL AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2718
Mailing Address - Country:US
Mailing Address - Phone:718-775-8507
Mailing Address - Fax:
Practice Address - Street 1:105 DANIEL AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2718
Practice Address - Country:US
Practice Address - Phone:718-775-8507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No251S00000XAgenciesCommunity/Behavioral Health