Provider Demographics
NPI:1710692173
Name:OLYMPIC MEDICAL LLC
Entity Type:Organization
Organization Name:OLYMPIC MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:AGBOR
Authorized Official - Suffix:
Authorized Official - Credentials:MR
Authorized Official - Phone:712-221-5827
Mailing Address - Street 1:4823 NE OAK LN
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-1851
Mailing Address - Country:US
Mailing Address - Phone:712-221-5827
Mailing Address - Fax:
Practice Address - Street 1:4823 NE OAK LN
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-1851
Practice Address - Country:US
Practice Address - Phone:712-221-5827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-19
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities