Provider Demographics
NPI:1699082446
Name:OLIVET MEDICAL MINISTRY
Entity type:Organization
Organization Name:OLIVET MEDICAL MINISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:SOCIAL WORKER
Authorized Official - Phone:757-886-0608
Mailing Address - Street 1:1620 OLD WILLIAMSBURG RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23690-3910
Mailing Address - Country:US
Mailing Address - Phone:757-886-0608
Mailing Address - Fax:757-369-3821
Practice Address - Street 1:1620 OLD WILLIAMSBURG RD
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23690-3910
Practice Address - Country:US
Practice Address - Phone:757-886-0608
Practice Address - Fax:757-369-3821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164154261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care