Provider Demographics
NPI:1962599472
Name:OLSEN, JOSHUA BOONE (DC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:BOONE
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 403
Mailing Address - Street 2:
Mailing Address - City:HAGERMAN
Mailing Address - State:ID
Mailing Address - Zip Code:83332-0403
Mailing Address - Country:US
Mailing Address - Phone:208-731-6241
Mailing Address - Fax:
Practice Address - Street 1:2621 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2942
Practice Address - Country:US
Practice Address - Phone:208-678-4100
Practice Address - Fax:208-678-4101
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-996111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807010300Medicaid
ID93259Medicare UPIN