Healthcare Provider Details

I. General information

NPI: 1043253362
Provider Name (Legal Business Name): CLARK H WOLF III DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 E MAIN ST
MEDFORD OR
97504
US

IV. Provider business mailing address

524 E MAIN ST
MEDFORD OR
97504
US

V. Phone/Fax

Practice location:
  • Phone: 541-773-2379
  • Fax: 541-773-2379
Mailing address:
  • Phone: 541-773-2379
  • Fax: 541-773-2379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberOR1404
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: