Provider Demographics
NPI:1184179954
Name:OLSON, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:OLSON
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 1:501 W KIEFFER RD
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9580
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 W KIEFFER RD
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9580
Practice Address - Country:US
Practice Address - Phone:219-879-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002915A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor