Healthcare Provider Details

I. General information

NPI: 1407557580
Provider Name (Legal Business Name): MARK KEVIN OLLER VIDUYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4249 HIGHWAY 411 STE 4
MADISONVILLE TN
37354-1544
US

IV. Provider business mailing address

1580 SAWGRASS CORPORATE PKWY STE 200
SUNRISE FL
33323-2869
US

V. Phone/Fax

Practice location:
  • Phone: 423-442-4034
  • Fax: 423-442-6463
Mailing address:
  • Phone: 954-739-4247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number012542
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: