Provider Demographics
NPI:1811604150
Name:OLUDAISI, ABIODUN EMMANUEL
Entity type:Individual
Prefix:
First Name:ABIODUN
Middle Name:EMMANUEL
Last Name:OLUDAISI
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 1:545 SANDY CT
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-7803
Mailing Address - Country:US
Mailing Address - Phone:312-978-1506
Mailing Address - Fax:
Practice Address - Street 1:455 COVENTRY LN STE 107/107A
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7571
Practice Address - Country:US
Practice Address - Phone:312-885-0283
Practice Address - Fax:779-356-4020
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227022762225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist