Healthcare Provider Details

I. General information

NPI: 1346606233
Provider Name (Legal Business Name): SETH WOLLES ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 SIOUX POINT RD
DAKOTA DUNES SD
57049
US

IV. Provider business mailing address

3601 LAFAYETTE ST
SIOUX CITY IA
51104-1737
US

V. Phone/Fax

Practice location:
  • Phone: 605-217-2667
  • Fax:
Mailing address:
  • Phone: 605-595-3987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number079077
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: