Healthcare Provider Details

I. General information

NPI: 1669179164
Provider Name (Legal Business Name): JERALD OLVIDO MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2023
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7945 WOLF RIVER BLVD
GERMANTOWN TN
38138-1762
US

IV. Provider business mailing address

9027 SUMMER GROVE CV
CORDOVA TN
38018-7498
US

V. Phone/Fax

Practice location:
  • Phone: 901-683-0055
  • Fax:
Mailing address:
  • Phone: 901-832-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number22601
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: