Healthcare Provider Details

I. General information

NPI: 1073178703
Provider Name (Legal Business Name): OLAF RUSSELL GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 S ABILENE ST STE 100
AURORA CO
80014-2363
US

IV. Provider business mailing address

108 TWIN CREEK CIR
DRIPPING SPRINGS TX
78620-3021
US

V. Phone/Fax

Practice location:
  • Phone: 720-507-4779
  • Fax: 833-941-5047
Mailing address:
  • Phone: 310-600-2751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberAP139504
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP139504
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: