Healthcare Provider Details

I. General information

NPI: 1184046054
Provider Name (Legal Business Name): OLIVER VIBOOLKIJ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1891 EFFIE ST
LOS ANGELES CA
90026-1711
US

IV. Provider business mailing address

1891 EFFIE ST
LOS ANGELES CA
90026-1711
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-2000
  • Fax: 323-666-1417
Mailing address:
  • Phone: 323-644-2000
  • Fax: 323-666-1417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: