Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2562-012 | WI |
NPI | 1235493388 |
---|---|
Provider Name | Richard Lee Olson |
First Address | Medford, WI 54451-1307 |
Second Address | Medford, WI 54451-1307 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2012 |
Last Update Date | 23/05/2017 |