Provider Demographics
NPI:1730679143
Name:OLVERA, CARMEN DE LOURDES
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:DE LOURDES
Last Name:OLVERA
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 1:400 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-2670
Mailing Address - Country:US
Mailing Address - Phone:321-320-7195
Mailing Address - Fax:
Practice Address - Street 1:400 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-2670
Practice Address - Country:US
Practice Address - Phone:321-320-7195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLO416104699010343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)