=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114791530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAFO CHIROPRACTIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2023
-----------------------------------------------------
Last Update Date | 11/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 TOLL HOUSE AVE STE 205
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21701-5901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-627-2342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10980 SASSAN LN
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21742-4069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-627-2342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. ERIC WAFO
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 508-627-2342
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------