1679534192 NPI number — DR. BERNADETTE LOUISE OLSON ATC, AT

Table of content: DR. BERNADETTE LOUISE OLSON ATC, AT (NPI 1679534192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679534192 NPI number — DR. BERNADETTE LOUISE OLSON ATC, AT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
BERNADETTE
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ATC, AT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679534192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
423 HANSINA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VOLGA
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57071-2122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-627-5921
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11TH STREET AND 16TH AVENUE
Provider Second Line Business Practice Location Address:
SOUTH DAKOTA STATE UNIVERSITY
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57007-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-688-5022
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  0059 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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