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General NPI Number Information
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NPI Number | 1013283563
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Entity Type | Organization
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Legal Business Name | WOLF SPECIFIC, INC
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Dates
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Enumeration Date | 03/29/2012
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Last Update Date | 08/28/2015
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Provider Practice Location Address
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Address Line | 1697 VERNON RD STE A
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City | LAGRANGE
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State | GA
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Zip | 30240-4180
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Country | US
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Telephone | 706-415-5245
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Fax |
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Provider Business Mailing Address
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Address Line | 1697 VERNON RD STE A
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City | LAGRANGE
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State | GA
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Zip | 30240-4180
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Country | US
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Telephone | 706-415-5245
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MATTHEW TYLER WOLFERTZ
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Credential | D.C.
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Telephone | 706-756-5422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | CHIR008690
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License Number State | GA
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