Healthcare Provider Details

I. General information

NPI: 1346456027
Provider Name (Legal Business Name): MRS. SALLIE OLOMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 E FAIR ST
GARDEN CITY KS
67846-3732
US

IV. Provider business mailing address

2108 E FAIR ST
GARDEN CITY KS
67846-3732
US

V. Phone/Fax

Practice location:
  • Phone: 620-271-2115
  • Fax: 620-275-6582
Mailing address:
  • Phone: 620-271-2115
  • Fax: 620-275-6582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1701601
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: