Provider Demographics
NPI:1336163476
Name:OLAVESON, GARY L (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:OLAVESON
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 1:645 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5596
Mailing Address - Country:US
Mailing Address - Phone:208-552-9886
Mailing Address - Fax:208-552-9843
Practice Address - Street 1:657 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5596
Practice Address - Country:US
Practice Address - Phone:208-552-9886
Practice Address - Fax:208-552-9843
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA871111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010025345OtherBLUE SHIELD
IDC4546OtherBLUE CROSS
1674048Medicare ID - Type Unspecified
IDC4546OtherBLUE CROSS