Provider Demographics
NPI:1083226807
Name:OLLOR, GODWIN LALE
Entity Type:Individual
Prefix:
First Name:GODWIN
Middle Name:LALE
Last Name:OLLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-3006
Mailing Address - Country:US
Mailing Address - Phone:651-795-1348
Mailing Address - Fax:
Practice Address - Street 1:222 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-3006
Practice Address - Country:US
Practice Address - Phone:651-795-1348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide