Provider Demographics
NPI:1083880322
Name:TESORO, OLYMPHIA ROLDAN (PT)
Entity Type:Individual
Prefix:
First Name:OLYMPHIA
Middle Name:ROLDAN
Last Name:TESORO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 ROYAL SAINT GEORGE DR
Mailing Address - Street 2:STE. 105
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8955
Mailing Address - Country:US
Mailing Address - Phone:630-527-6370
Mailing Address - Fax:630-527-6374
Practice Address - Street 1:790 ROYAL SAINT GEORGE DR
Practice Address - Street 2:STE. 105
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8955
Practice Address - Country:US
Practice Address - Phone:630-527-6370
Practice Address - Fax:630-527-6374
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006433225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205190Medicare PIN