Provider Demographics
NPI:1093856775
Name:OLSEN, KEITH L (DC)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:L
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 N SCHNOOR ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-3602
Mailing Address - Country:US
Mailing Address - Phone:559-661-1045
Mailing Address - Fax:559-661-1078
Practice Address - Street 1:1521 N SCHNOOR ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-3602
Practice Address - Country:US
Practice Address - Phone:559-661-1045
Practice Address - Fax:559-661-1078
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU65110Medicare UPIN
CADC0221110Medicare ID - Type UnspecifiedMEDICARE ID