Provider Demographics
NPI:1588739858
Name:OLIVE AMBULATORY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:OLIVE AMBULATORY SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:12101 WOODCREST EXECUTIVE DR
Mailing Address - Street 2:STE 101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5047
Mailing Address - Country:US
Mailing Address - Phone:314-576-4500
Mailing Address - Fax:314-576-4503
Practice Address - Street 1:12101 WOODCREST EXECUTIVE DR
Practice Address - Street 2:STE 101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5047
Practice Address - Country:US
Practice Address - Phone:314-576-4500
Practice Address - Fax:314-576-4503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO177261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507784403Medicaid
MO507784403Medicaid
000040065Medicare PIN