MEDICARE: THE OLISA FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor
2	177F00000X	Lodging Provider
3	251K00000X	Public Health or Welfare Agency
4	251V00000X	Voluntary or Charitable Agency
5	261QR1100X	Research Clinic/Center
6	331L00000X	Blood Bank
7	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	RM (NRCM) 55214696	NM
8	335G00000X	Medical Foods Supplier	NAFDAC A7469L	ZZ
9	347E00000X	Transportation Broker
10	291U00000X	Clinical Medical Laboratory	M (ASCP) 3555	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9068479	OTHER		CAP
2	8725411	OTHER		CLIA-CAP

General Provider Information

NPI Number	:	1013284546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE OLISA FOUNDATION

Provider Business Mailing Address
First Line	:	3601 PICKETT RD UNIT 2121
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-8107
Country	:	US
Telephone Number	:	915-208-4431
Fax Number	:

Provider Business Practice Location Address
First Line	:	7362 REMCON CIR STE 644
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-1623
Country	:	US
Telephone Number	:	915-208-4431
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. NZEDEGWU ROBERT OLISA III
Credential	:	PHD, MPA, MS, MASCP
Telephone Number	:	202-855-3479

Provider Enumeration Date	:	11/29/2011
Last Update Date	:	02/02/2025

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Directions to “THE OLISA FOUNDATION ” Practice Location

Language	Start Address	Practice Location

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