Healthcare Provider Details

I. General information

NPI: 1760453716
Provider Name (Legal Business Name): DR. JEFF LYLE WOLFF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2006
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W GRAND XING
MOBRIDGE SD
57601-2051
US

IV. Provider business mailing address

622 W GRAND XING
MOBRIDGE SD
57601-2051
US

V. Phone/Fax

Practice location:
  • Phone: 605-845-5757
  • Fax:
Mailing address:
  • Phone: 605-845-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number710
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: