Provider Demographics
NPI:1013284546
Name:THE OLISA FOUNDATION
Entity type:Organization
Organization Name:THE OLISA FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NZEDEGWU
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:OLISA
Authorized Official - Suffix:III
Authorized Official - Credentials:PHD, MPA, MS, MASCP
Authorized Official - Phone:202-855-3479
Mailing Address - Street 1:3601 PICKETT RD UNIT 2121
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-8107
Mailing Address - Country:US
Mailing Address - Phone:915-208-4431
Mailing Address - Fax:
Practice Address - Street 1:7362 REMCON CIR STE 644
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-1623
Practice Address - Country:US
Practice Address - Phone:915-208-4431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2025-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 177F00000X, 251K00000X, 251V00000X, 261QR1100X, 331L00000X, 347E00000X
NMRM (NRCM) 55214696332BP3500X
ZZNAFDAC A7469L335G00000X
NMM (ASCP) 3555291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No171W00000XOther Service ProvidersContractor
No177F00000XOther Service ProvidersLodging
No251K00000XAgenciesPublic Health or Welfare
No251V00000XAgenciesVoluntary or Charitable
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch
No331L00000XSuppliersBlood Bank
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No335G00000XSuppliersMedical Foods Supplier
No347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
9068479OtherCAP
8725411OtherCLIA-CAP