Provider Demographics
NPI:1255842779
Name:OLSON CC WELLNESS LLC
Entity Type:Organization
Organization Name:OLSON CC WELLNESS LLC
Other - Org Name:OLSON CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-417-1627
Mailing Address - Street 1:20610 ENFIELD AVE N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-8137
Mailing Address - Country:US
Mailing Address - Phone:715-417-1627
Mailing Address - Fax:
Practice Address - Street 1:307 N CASCADE STREET
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020
Practice Address - Country:US
Practice Address - Phone:715-294-3211
Practice Address - Fax:715-417-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4859-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty