MEDICARE: OLGA AMBROSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	126414444701	UT

General Provider Information

NPI Number	:	1689495780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLGA AMBROSE

Provider Business Mailing Address
First Line	:	6405 S 3000 E STE 100
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84121-6975
Country	:	US
Telephone Number	:	310-359-2931
Fax Number	:

Provider Business Practice Location Address
First Line	:	6405 S 3000 E STE 100
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84121-6975
Country	:	US
Telephone Number	:	310-359-2931
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2024
Last Update Date	:	10/21/2024

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Directions to “ OLGA AMBROSE ” Practice Location

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