Basic Information
| Provider Information | |||||||||
| NPI: | 1639494073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIVE | ||||||||
| FirstName: | DARRYL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LMT, RYT, MBA, MHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 CORONA RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652032582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732341800 | ||||||||
| FaxNumber: | 8167530804 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 CORONA RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652032582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732341800 | ||||||||
| FaxNumber: | 5732341799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2010 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 09980-01073 | KS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 226300000X | YA-34381 | KS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Kinesiotherapist | 363A00000X | 1502108 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2019013315 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.