Provider Demographics
NPI:1548906837
Name:ENIDAMMY FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:ENIDAMMY FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:KEHINDE
Authorized Official - Middle Name:
Authorized Official - Last Name:IBITOLA
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:973-493-0026
Mailing Address - Street 1:2177 OAK TREE RD STE 206
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1082
Mailing Address - Country:US
Mailing Address - Phone:908-755-4000
Mailing Address - Fax:908-755-4006
Practice Address - Street 1:2177 OAK TREE RD STE 206
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1082
Practice Address - Country:US
Practice Address - Phone:908-755-4000
Practice Address - Fax:908-755-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care