Provider Demographics
NPI:1720618309
Name:OLSON, BRENTON L (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:L
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 1:1030 SE MURPHY BLVD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-5043
Mailing Address - Country:US
Mailing Address - Phone:417-623-2828
Mailing Address - Fax:
Practice Address - Street 1:1030 SE MURPHY BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-5043
Practice Address - Country:US
Practice Address - Phone:417-623-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020002181111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor