Healthcare Provider Details

I. General information

NPI: 1295390508
Provider Name (Legal Business Name): JACOB OLVERA LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 HERON AVE
MCALLEN TX
78504-2049
US

IV. Provider business mailing address

2522 BUDDY OWENS AVE
MCALLEN TX
78504-5464
US

V. Phone/Fax

Practice location:
  • Phone: 956-283-6754
  • Fax:
Mailing address:
  • Phone: 956-630-1116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number348185
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: