1063576171 NPI number — ARLESE CHARLETTE OLSON O.D

Table of content: ARLESE CHARLETTE OLSON O.D (NPI 1063576171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063576171 NPI number — ARLESE CHARLETTE OLSON O.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
ARLESE
Provider Middle Name:
CHARLETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIVILS
Provider Other First Name:
ARLESE
Provider Other Middle Name:
CHARLETTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063576171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
229 FRENCHMANS CREEK WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33884-1810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-676-0911
Provider Business Mailing Address Fax Number:
863-676-0715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
762 EAGLE RIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WALES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33859-4740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-676-0911
Provider Business Practice Location Address Fax Number:
863-676-0715
Provider Enumeration Date:
12/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC2856 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 621030900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".