1003109489 NPI number — TONYA NICOLE OLIVER

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 1003109489 NPI number — TONYA NICOLE OLIVER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TONYA NICOLE OLIVER
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:
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:
1003109489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5494 BROWN ROAD
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
HAZELWOOD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-731-7107
Provider Business Mailing Address Fax Number:
314-731-7812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5494 BROWN ROAD
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
HAZELWOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-731-7107
Provider Business Practice Location Address Fax Number:
314-731-7812
Provider Enumeration Date:
05/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
OLIVER
Authorized Official First Name:
TONYA
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
314-614-8702

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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