Provider Demographics
NPI:1851007132
Name:OLIVINE, S.C.
Entity Type:Organization
Organization Name:OLIVINE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/INCORPORATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-705-3238
Mailing Address - Street 1:10278 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-6524
Mailing Address - Country:US
Mailing Address - Phone:262-705-3238
Mailing Address - Fax:
Practice Address - Street 1:7137 236TH AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WI
Practice Address - Zip Code:53168-8975
Practice Address - Country:US
Practice Address - Phone:262-800-4672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty