Provider Demographics
NPI:1629751474
Name:OLIVAREZ, ANTONIO R (LMT)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:R
Last Name:OLIVAREZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 S RIDGE RD APT 836
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-2273
Mailing Address - Country:US
Mailing Address - Phone:469-992-3056
Mailing Address - Fax:
Practice Address - Street 1:9300 JOHN HICKMAN PKWY STE 104
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-5936
Practice Address - Country:US
Practice Address - Phone:469-992-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT110494225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty