Provider Demographics
NPI:1750568036
Name:OLSEN CHIROPRACTIC CENTER PLLC
Entity type:Organization
Organization Name:OLSEN CHIROPRACTIC CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:B
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-678-4100
Mailing Address - Street 1:2621 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-5084
Mailing Address - Country:US
Mailing Address - Phone:208-678-4100
Mailing Address - Fax:208-678-4101
Practice Address - Street 1:2621 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-5084
Practice Address - Country:US
Practice Address - Phone:208-678-4100
Practice Address - Fax:208-678-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1675191Medicare PIN
ID93259Medicare UPIN