Provider Demographics
NPI:1780117044
Name:ADEDIRAN, ADENIYI
Entity type:Individual
Prefix:
First Name:ADENIYI
Middle Name:
Last Name:ADEDIRAN
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 1:200 DAHLBERG BLVD APT 7
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-1714
Mailing Address - Country:US
Mailing Address - Phone:512-822-1073
Mailing Address - Fax:
Practice Address - Street 1:200 DAHLBERG BLVD APT 7
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-1714
Practice Address - Country:US
Practice Address - Phone:512-822-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX374U00000X385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child