=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275590820
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA ELTER OLSON ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 S TIMBERLAND DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75901-4065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-632-5511
-----------------------------------------------------
Fax | 936-632-5633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 COUNTY ROAD 2041
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75965-0470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-715-0676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT2588
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------