Healthcare Provider Details

I. General information

NPI: 1588739858
Provider Name (Legal Business Name): OLIVE AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12101 WOODCREST EXECUTIVE DR STE 101
SAINT LOUIS MO
63141-5047
US

IV. Provider business mailing address

12101 WOODCREST EXECUTIVE DR STE 101
SAINT LOUIS MO
63141-5047
US

V. Phone/Fax

Practice location:
  • Phone: 314-576-4500
  • Fax: 314-576-4503
Mailing address:
  • Phone: 314-576-4500
  • Fax: 314-576-4503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number177
License Number StateMO

VIII. Authorized Official

Name: JENETHA D MORAN
Title or Position: OFFICER / AUTHORIZED OFFICIAL
Credential:
Phone: 972-763-3893