=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508189507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLSEN CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2010
-----------------------------------------------------
Last Update Date | 07/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 159 BUTLER RD SUITE 2A
-----------------------------------------------------
City | KITTANNING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16201-2328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-548-1040
-----------------------------------------------------
Fax | 724-548-1044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 159 BUTLER RD SUITE 2A
-----------------------------------------------------
City | KITTANNING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16201-2328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-548-1040
-----------------------------------------------------
Fax | 724-548-1044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. RYAN WILLIAM OLSEN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 724-548-1040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC010115
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------