Provider Demographics
NPI:1144518721
Name:OLLAE MEDICAL DIAGNOSTIC LABORATORY INC
Entity type:Organization
Organization Name:OLLAE MEDICAL DIAGNOSTIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ONESIMO
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-710-1601
Mailing Address - Street 1:5529 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2218
Mailing Address - Country:US
Mailing Address - Phone:708-710-1601
Mailing Address - Fax:
Practice Address - Street 1:5529 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2218
Practice Address - Country:US
Practice Address - Phone:708-710-1601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory