Provider Demographics
NPI:1801997143
Name:OLSEN, BLAINE ROBERT (DC)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:ROBERT
Last Name:OLSEN
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 1:1921 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1973
Mailing Address - Country:US
Mailing Address - Phone:701-222-2252
Mailing Address - Fax:701-222-3645
Practice Address - Street 1:1921 N 13TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1973
Practice Address - Country:US
Practice Address - Phone:701-222-2252
Practice Address - Fax:701-222-3645
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND664111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
N21894Medicare PIN