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General NPI Number Information
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NPI Number | 1407488182
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Entity Type | Organization
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Legal Business Name | TOM WULF MD LLC
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Dates
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Enumeration Date | 02/10/2020
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Last Update Date | 05/11/2020
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Provider Practice Location Address
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Address Line | 607 W COUNTRY CLUB RD
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City | ROSWELL
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State | NM
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Zip | 88201-5211
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Country | US
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Telephone | 575-208-7795
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Fax | 575-208-7785
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Provider Business Mailing Address
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Address Line | 313 W COUNTRY CLUB RD STE 15
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City | ROSWELL
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State | NM
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Zip | 88201-5804
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Country | US
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Telephone | 575-208-7795
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Fax | 575-208-7785
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Authorized Official
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Title or Position | OWNER
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Name | THOMAS WULF
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Credential | MD
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Telephone | 575-208-7795
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251G00000X
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Taxonomy Name | Community Based Hospice Care Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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