Healthcare Provider Details

I. General information

NPI: 1265892806
Provider Name (Legal Business Name): OLON WAFER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BAILEY AVE STE 2
NEEDLES CA
92363-3105
US

IV. Provider business mailing address

2158 SUTTER WAY APT 202
BULLHEAD CITY AZ
86442-9536
US

V. Phone/Fax

Practice location:
  • Phone: 760-326-9313
  • Fax:
Mailing address:
  • Phone: 928-293-1773
  • Fax:

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: