Provider Demographics
NPI:1790071132
Name:OLSON, ROSS
Entity Type:Individual
Prefix:
First Name:ROSS
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 1:506 CENTER ST E
Mailing Address - Street 2:
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751-1511
Mailing Address - Country:US
Mailing Address - Phone:701-306-9493
Mailing Address - Fax:
Practice Address - Street 1:306 MAIN AVE N
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1820
Practice Address - Country:US
Practice Address - Phone:218-463-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3244152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist