Basic Information
| Provider Information | |||||||||
| NPI: | 1174960629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OLAOLU INCORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 81452 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891801452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 10301 JEFFREYS ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890523922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2013 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | LABRECQUE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCOUNTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7024533799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD60329818 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 14674 | 01 | NV | NV LICENSE | OTHER | MD60329818 | 01 | WA | WA LIC | OTHER |