Healthcare Provider Details

I. General information

NPI: 1164836003
Provider Name (Legal Business Name): OLIVE EGBUNIWE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 RONALD REAGAN DR STE C
EVANS GA
30809-7607
US

IV. Provider business mailing address

629 RONALD REAGAN DR STE C
EVANS GA
30809-7607
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-0319
  • Fax: 706-868-3719
Mailing address:
  • Phone: 706-868-0319
  • Fax: 706-868-3719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: