Basic Information
| Provider Information | |||||||||
| NPI: | 1033551619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEME | ||||||||
| FirstName: | MOPELOLA | ||||||||
| MiddleName: | BEATRICE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEME-ADAGUN | ||||||||
| OtherFirstName: | MOPELOLA | ||||||||
| OtherMiddleName: | BEATRICE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2080 S E ST | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924082773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093889191 | ||||||||
| FaxNumber: | 9093889195 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 S E ST | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924082773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093889191 | ||||||||
| FaxNumber: | 9093889195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2013 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 493927 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1124100383 | 05 | CA | MEDICAID |