Healthcare Provider Details

I. General information

NPI: 1093544975
Provider Name (Legal Business Name): JORGE F OLMO MT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 BROAD ST
CLIFTON NJ
07013-3346
US

IV. Provider business mailing address

45 EISENHOWER DR STE 330
PARAMUS NJ
07652-1416
US

V. Phone/Fax

Practice location:
  • Phone: 844-639-3539
  • Fax:
Mailing address:
  • Phone: 184-463-9353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18KT00564100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: