Provider Demographics
NPI:1528247459
Name:OLLAE MEDICAL LABORATORY
Entity type:Organization
Organization Name:OLLAE MEDICAL LABORATORY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL LAB
Authorized Official - Prefix:MRS
Authorized Official - First Name:ONESIMO
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:708-692-5499
Mailing Address - Street 1:1809 HOME AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1669
Mailing Address - Country:US
Mailing Address - Phone:708-692-5499
Mailing Address - Fax:
Practice Address - Street 1:1809 HOME AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-1669
Practice Address - Country:US
Practice Address - Phone:708-692-5499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLLAE MEDICAL LAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-28
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory