Healthcare Provider Details

I. General information

NPI: 1538715248
Provider Name (Legal Business Name): OCTAVIA LOUISE MCQUITTY OCTAVIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2019
Last Update Date: 08/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 ROCHEPORT ST
FAYETTE MO
65248-1290
US

IV. Provider business mailing address

504 ROCHEPORT ST
FAYETTE MO
65248-1290
US

V. Phone/Fax

Practice location:
  • Phone: 660-888-0669
  • Fax:
Mailing address:
  • Phone: 660-888-0669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License NumberNONE
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: