Healthcare Provider Details

I. General information

NPI: 1548087422
Provider Name (Legal Business Name): MIA OLSON
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: HENDRIX OLSON

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 PARKWAY DR STE AB
SANTA FE NM
87507-7322
US

IV. Provider business mailing address

PO BOX 449
TESUQUE NM
87574-0449
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-6158
  • Fax:
Mailing address:
  • Phone: 505-983-6158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: