Healthcare Provider Details

I. General information

NPI: 1619345709
Provider Name (Legal Business Name): CHARLENE OLMSTED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 BAKER ST E STE A
COSTA MESA CA
92626-4566
US

IV. Provider business mailing address

275 EAST BAKER STREET SUITE A
COSTA MESA CA
92626
US

V. Phone/Fax

Practice location:
  • Phone: 714-361-6760
  • Fax: 714-361-6168
Mailing address:
  • Phone: 714-361-6760
  • Fax: 714-361-6168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: