Provider Demographics
NPI:1649878687
Name:AGORO, AYOBAMI NOHEEM (CEO)
Entity type:Individual
Prefix:
First Name:AYOBAMI
Middle Name:NOHEEM
Last Name:AGORO
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12362 W JOBLANCA RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-3130
Mailing Address - Country:US
Mailing Address - Phone:202-290-7492
Mailing Address - Fax:
Practice Address - Street 1:12362 W JOBLANCA RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-3130
Practice Address - Country:US
Practice Address - Phone:202-290-7492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
00OtherN/A