Provider Demographics
NPI:1740514959
Name:MABELTON ENTERPRISE
Entity type:Organization
Organization Name:MABELTON ENTERPRISE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:OLUFUNMILAYO
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEJOKUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-728-2624
Mailing Address - Street 1:26 ANASTASIA DR SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1461
Mailing Address - Country:US
Mailing Address - Phone:850-728-2624
Mailing Address - Fax:
Practice Address - Street 1:1338 VETERANS MEMORIAL HWY SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-3112
Practice Address - Country:US
Practice Address - Phone:850-728-2624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment