=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124429733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLIVIERI URBAN CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2014
-----------------------------------------------------
Last Update Date | 09/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4512 RALPH LN
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75227-1845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-381-1910
-----------------------------------------------------
Fax | 214-381-2868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6300 SAMUELL BLVD SUITE 120
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75228-7137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-381-1910
-----------------------------------------------------
Fax | 214-381-2868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JULIO C OLIVIERI JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-381-1910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------