Basic Information
| Provider Information | |||||||||
| NPI: | 1932572468 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIVER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 CENTENARY BLVD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711043356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186819935 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2620 CENTENARY BLVD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186819935 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2015 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 007016682 | LA | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.