Provider Demographics
NPI:1053959411
Name:NUGAHEALTH PRIMARY CARE LLC
Entity type:Organization
Organization Name:NUGAHEALTH PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:OMOBOLANLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ADENUGA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:240-755-1452
Mailing Address - Street 1:11636 PORT ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-5193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11636 PORT ROYAL AVE
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-5193
Practice Address - Country:US
Practice Address - Phone:240-755-1452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center