Healthcare Provider Details

I. General information

NPI: 1629323340
Provider Name (Legal Business Name): OLIVIA OLIVAS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 EUBANK BLVD SE BLDG 832
ALBUQUERQUE NM
87123-3453
US

IV. Provider business mailing address

1515 EUBANK BLVD SE BLDG 832
ALBUQUERQUE NM
87123-3453
US

V. Phone/Fax

Practice location:
  • Phone: 505-845-0082
  • Fax: 505-845-8190
Mailing address:
  • Phone: 505-845-0082
  • Fax: 505-845-8190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3306
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: