Provider Demographics
NPI:1831683036
Name:OLIVE VERDE COMPANY LLC
Entity type:Organization
Organization Name:OLIVE VERDE COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD/N
Authorized Official - Phone:813-546-1143
Mailing Address - Street 1:2231 VALTERRA VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-4412
Mailing Address - Country:US
Mailing Address - Phone:813-546-1143
Mailing Address - Fax:813-684-0804
Practice Address - Street 1:859 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6280
Practice Address - Country:US
Practice Address - Phone:813-546-1143
Practice Address - Fax:813-684-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4125261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center