1114433653 NPI number — RONALD E OLER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114433653 NPI number — RONALD E OLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RONALD E OLER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114433653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 845
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROVELAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95321-0845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-962-0662
Provider Business Mailing Address Fax Number:
877-422-8884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18687 MAIN ST STE D1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROVELAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95321-9463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-962-0662
Provider Business Practice Location Address Fax Number:
877-422-8884
Provider Enumeration Date:
12/20/2017

Additional Information

Authorized Official

Authorized Official Last Name:
OLER
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
209-768-5514

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC10746 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DC01074600 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 350052177 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: DC0107460 . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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