Healthcare Provider Details

I. General information

NPI: 1598988743
Provider Name (Legal Business Name): LEE WOLF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4066 320TH ST
MAPLETON IA
51034-8005
US

IV. Provider business mailing address

4066 320TH ST
MAPLETON IA
51034-8005
US

V. Phone/Fax

Practice location:
  • Phone: 712-883-2893
  • Fax: 712-883-2894
Mailing address:
  • Phone: 712-883-2893
  • Fax: 712-883-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State

VIII. Authorized Official

Name: LEE WOLF
Title or Position: OWNER
Credential:
Phone: 712-883-2893