Provider Demographics
NPI:1417044363
Name:OLSON, KENNETH J (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:OLSON
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 1:2116 W GALENA BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3533
Mailing Address - Country:US
Mailing Address - Phone:630-897-1895
Mailing Address - Fax:630-897-2043
Practice Address - Street 1:2116 W GALENA BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3533
Practice Address - Country:US
Practice Address - Phone:630-897-1895
Practice Address - Fax:630-897-2043
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008765111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
581870Medicare ID - Type Unspecified
IL350051278Medicare PIN
U80186Medicare UPIN