Healthcare Provider Details

I. General information

NPI: 1255842779
Provider Name (Legal Business Name): OLSON CC WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N CASCADE STREET
OSCEOLA WI
54020
US

IV. Provider business mailing address

20610 ENFIELD AVE N
FOREST LAKE MN
55025-8137
US

V. Phone/Fax

Practice location:
  • Phone: 715-294-3211
  • Fax: 715-417-3103
Mailing address:
  • Phone: 715-417-1627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4859-12
License Number StateWI

VIII. Authorized Official

Name: DAVID OLSON
Title or Position: SOLE MEMBER
Credential: DC
Phone: 715-417-1627