Provider Demographics
NPI:1669004388
Name:VEDAD, OLIVIA LLEWELLYN
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LLEWELLYN
Last Name:VEDAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7164
Mailing Address - Country:US
Mailing Address - Phone:843-377-7926
Mailing Address - Fax:
Practice Address - Street 1:757 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7164
Practice Address - Country:US
Practice Address - Phone:843-377-7926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
75729414OtherNONE