Provider Demographics
NPI:1669652939
Name:LISA OLIVO
Entity type:Organization
Organization Name:LISA OLIVO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OLIVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-561-8899
Mailing Address - Street 1:1009 ASHPORT ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2323
Mailing Address - Country:US
Mailing Address - Phone:909-561-8899
Mailing Address - Fax:
Practice Address - Street 1:117 E HARRY BRIDGES BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-5825
Practice Address - Country:US
Practice Address - Phone:310-549-8383
Practice Address - Fax:310-549-9305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service