Healthcare Provider Details

I. General information

NPI: 1629220462
Provider Name (Legal Business Name): HEATHER LARAE OLMOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2733 QUAIL RUN DR
SIERRA VISTA AZ
85635-3448
US

IV. Provider business mailing address

2733 QUAIL RUN DR
SIERRA VISTA AZ
85635-3448
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-2371
  • Fax:
Mailing address:
  • Phone: 520-459-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number11412
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: