Provider Demographics
NPI:1467173674
Name:OLYMPUS MEDICAL WELLNESS CENTER CORP
Entity type:Organization
Organization Name:OLYMPUS MEDICAL WELLNESS CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIAZ GIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-872-6133
Mailing Address - Street 1:468 NW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-3040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3611 SW 87TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4307
Practice Address - Country:US
Practice Address - Phone:305-424-7343
Practice Address - Fax:305-547-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-06
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11151515OtherINS