Healthcare Provider Details

I. General information

NPI: 1194652826
Provider Name (Legal Business Name): EDWIN OLIVERAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4559 CUPOLA DR
LORAIN OH
44053-1662
US

IV. Provider business mailing address

4559 CUPOLA DR
LORAIN OH
44053-1662
US

V. Phone/Fax

Practice location:
  • Phone: 440-371-0517
  • Fax:
Mailing address:
  • Phone: 440-371-0517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: