Healthcare Provider Details

I. General information

NPI: 1518548650
Provider Name (Legal Business Name): OLIVIA C EADE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 HENRY ST STE 201
ALTON IL
62002-6326
US

IV. Provider business mailing address

307 HENRY ST STE 201
ALTON IL
62002-6326
US

V. Phone/Fax

Practice location:
  • Phone: 618-610-5551
  • Fax: 618-433-8777
Mailing address:
  • Phone: 618-610-5551
  • Fax: 618-433-8777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3397
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: