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General NPI Number Information
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NPI Number | 1831683036
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Entity Type | Organization
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Legal Business Name | OLIVE VERDE COMPANY LLC
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Dates
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Enumeration Date | 06/20/2018
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Last Update Date | 09/09/2019
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Provider Practice Location Address
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Address Line | 859 W LUMSDEN RD
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City | BRANDON
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State | FL
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Zip | 33511-6280
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Country | US
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Telephone | 813-546-1143
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Fax | 813-684-0804
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Provider Business Mailing Address
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Address Line | 2231 VALTERRA VISTA WAY
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City | VALRICO
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State | FL
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Zip | 33594-4412
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Country | US
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Telephone | 813-546-1143
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Fax | 813-684-0804
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Authorized Official
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Title or Position | OWNER
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Name | MRS. DIANNA K LOPEZ
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Credential | RDN, LD/N
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Telephone | 813-546-1143
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | ND4125
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License Number State | FL
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