Provider Demographics
NPI:1255331179
Name:OLIVA MEDICAL INC
Entity Type:Organization
Organization Name:OLIVA MEDICAL INC
Other - Org Name:DURAMED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-699-2247
Mailing Address - Street 1:760 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-4142
Mailing Address - Country:US
Mailing Address - Phone:866-699-2247
Mailing Address - Fax:866-699-2244
Practice Address - Street 1:760 5TH ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4142
Practice Address - Country:US
Practice Address - Phone:866-699-2247
Practice Address - Fax:866-699-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103129332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03078FMedicaid
CA4104070001Medicare NSC