Provider Demographics
NPI:1134530314
Name:OLGA IAROSSEVITCH LLC
Entity type:Organization
Organization Name:OLGA IAROSSEVITCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:IAROSSEVITCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-271-4338
Mailing Address - Street 1:105 E PALMETTO PARK RD
Mailing Address - Street 2:B
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-4801
Mailing Address - Country:US
Mailing Address - Phone:561-271-4338
Mailing Address - Fax:
Practice Address - Street 1:2090 S CONFERENCE DR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-3114
Practice Address - Country:US
Practice Address - Phone:561-271-4338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104365363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty