Provider Demographics
NPI:1124194113
Name:RICHARD A OLSON
Entity Type:Organization
Organization Name:RICHARD A OLSON
Other - Org Name:ADVANCED CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-688-7777
Mailing Address - Street 1:300 EAST WAR MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-688-7777
Mailing Address - Fax:309-688-7779
Practice Address - Street 1:300 EAST WAR MEMORIAL DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-688-7777
Practice Address - Fax:309-688-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0007282057OtherBLUE CROSS BLUE SHIELD
L72746Medicare UPIN
IL555620Medicare ID - Type Unspecified