Provider Demographics
NPI:1427582352
Name:OLIVET MEDICAL MINISTRY, INC
Entity Type:Organization
Organization Name:OLIVET MEDICAL MINISTRY, INC
Other - Org Name:LACKEY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SALE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:757-886-0608
Mailing Address - Street 1:1620 OLD WILLIAMSBURG RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23690-3910
Mailing Address - Country:US
Mailing Address - Phone:757-886-0608
Mailing Address - Fax:757-968-5022
Practice Address - Street 1:1620 OLD WILLIAMSBURG RD
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23690-3910
Practice Address - Country:US
Practice Address - Phone:757-886-0608
Practice Address - Fax:757-968-5022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010039313336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy