Healthcare Provider Details

I. General information

NPI: 1639576713
Provider Name (Legal Business Name): MIRIAN OLMEDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 FAIR OAKS AVE STE 300
SOUTH PASADENA CA
91030-5805
US

IV. Provider business mailing address

211 PASADENA AVE
SOUTH PASADENA CA
91030-2919
US

V. Phone/Fax

Practice location:
  • Phone: 323-341-7770
  • Fax:
Mailing address:
  • Phone: 323-341-7770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: