Healthcare Provider Details

I. General information

NPI: 1790080240
Provider Name (Legal Business Name): DAVID GREGORY OLMEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 BAY BLVD STE D
CHULA VISTA CA
91911-7155
US

IV. Provider business mailing address

1124 BAY BLVD STE D
CHULA VISTA CA
91911-7155
US

V. Phone/Fax

Practice location:
  • Phone: 619-420-3620
  • Fax: 619-420-8722
Mailing address:
  • Phone: 619-420-3620
  • Fax: 619-420-8722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: