Provider Demographics
NPI:1538915798
Name:ROSS, OLIVER
Entity type:Individual
Prefix:
First Name:OLIVER
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 W INTERNATIONAL SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3566
Mailing Address - Country:US
Mailing Address - Phone:386-295-0786
Mailing Address - Fax:
Practice Address - Street 1:2090 S NOVA RD STE A127
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-8841
Practice Address - Country:US
Practice Address - Phone:386-341-6256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL1310861174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist