Provider Demographics
NPI:1013189521
Name:OLAVESON FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:OLAVESON FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLAVESON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-745-1109
Mailing Address - Street 1:135 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1449
Mailing Address - Country:US
Mailing Address - Phone:208-745-1109
Mailing Address - Fax:208-745-1811
Practice Address - Street 1:135 S STATE ST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1449
Practice Address - Country:US
Practice Address - Phone:208-745-1109
Practice Address - Fax:208-745-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1269111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty