Basic Information
| Provider Information | |||||||||
| NPI: | 1992460067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIEL | ||||||||
| FirstName: | OLUSESAN | ||||||||
| MiddleName: | BAMIDELE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1711 W TEMPLE ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900267329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139896100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1711 W TEMPLE ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900267329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139896100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2021 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 717779 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Vocational Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1780183335 | 05 | CA | MEDICAID |