Healthcare Provider Details

I. General information

NPI: 1730679143
Provider Name (Legal Business Name): MRS. CARMEN DE LOURDES OLVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MONTANA AVE
SAINT CLOUD FL
34769-2670
US

IV. Provider business mailing address

400 MONTANA AVE
SAINT CLOUD FL
34769-2670
US

V. Phone/Fax

Practice location:
  • Phone: 321-320-7195
  • Fax:
Mailing address:
  • Phone: 321-320-7195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberO416104699010
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: