=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225032196
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRIS M OLENECH V DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2005
-----------------------------------------------------
Last Update Date | 08/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3976 DIX HWY
-----------------------------------------------------
City | LINCOLN PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48146-3940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-386-5750
-----------------------------------------------------
Fax | 313-386-0579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3976 DIX HWY
-----------------------------------------------------
City | LINCOLN PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48146-3940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-386-5750
-----------------------------------------------------
Fax | 313-386-0579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | CO001358
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------