Basic Information
| Provider Information | |||||||||
| NPI: | 1760660831 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLE HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | OLE HEALTH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1141 PEAR TREE LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072541770 | ||||||||
| FaxNumber: | 7072541779 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 WASHINGTON ST. | ||||||||
| Address2: | |||||||||
| City: | CALISTOGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077092308 | ||||||||
| FaxNumber: | 7072512988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2008 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARDY | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7072541774 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 550000616 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.