MEDICARE: MR. GARY PAUL OLSEN LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT-08525	AZ
2	172M00000X	Mechanotherapist	MT-08525	AZ

General Provider Information

NPI Number	:	1679808760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY PAUL OLSEN LMT

Provider Business Mailing Address
First Line	:	4728 E WAVERLY ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-2736
Country	:	US
Telephone Number	:	520-449-2128
Fax Number	:	520-207-0712

Provider Business Practice Location Address
First Line	:	2560 E FORT LOWELL RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-1514
Country	:	US
Telephone Number	:	520-449-2128
Fax Number	:	520-207-0712

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2009
Last Update Date	:	03/17/2018

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