Healthcare Provider Details

I. General information

NPI: 1437664976
Provider Name (Legal Business Name): EARL E WOELTJE JR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 N BLOOMINGTON ST
STREATOR IL
61364-2087
US

IV. Provider business mailing address

PO BOX 516
STREATOR IL
61364-0516
US

V. Phone/Fax

Practice location:
  • Phone: 815-672-2195
  • Fax:
Mailing address:
  • Phone: 815-672-2195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. EARL ERNST WOELTJE JR.
Title or Position: OWNER
Credential: DDS
Phone: 815-672-2195