Healthcare Provider Details

I. General information

NPI: 1760953038
Provider Name (Legal Business Name): KYLE J OLSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

S69W15636 JANESVILLE RD
MUSKEGO WI
53150-9330
US

IV. Provider business mailing address

S69W15636 JANESVILLE RD
MUSKEGO WI
53150-9330
US

V. Phone/Fax

Practice location:
  • Phone: 262-446-9488
  • Fax: 262-446-9489
Mailing address:
  • Phone: 262-928-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14209
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: