Provider Demographics
NPI:1013284546
Name:THE OLISA FOUNDATION
Entity Type:Organization
Organization Name:THE OLISA FOUNDATION
Other - Org Name:AMERICAN JOURNAL OF BIOLOGICAL DEFENSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LABORATORY TECHNICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NZEDEGWU
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:OLISA
Authorized Official - Suffix:III
Authorized Official - Credentials:PHD; MPA; M(ASCP)
Authorized Official - Phone:915-208-4431
Mailing Address - Street 1:3601 PICKETT RD UNIT 2121
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-8107
Mailing Address - Country:US
Mailing Address - Phone:915-208-4431
Mailing Address - Fax:
Practice Address - Street 1:7362 REMCON CIR STE 644
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-1623
Practice Address - Country:US
Practice Address - Phone:915-208-4431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM (ASCP) 3555291U00000X
NMRM (NRCM) 55214696332BP3500X
ZZNAFDAC A7469L335G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No335G00000XSuppliersMedical Foods Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
9068479OtherCAP