=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679088454
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. ERIC PAUL WOLKE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2017
-----------------------------------------------------
Last Update Date | 12/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2225 PACIFIC BLVD SE STE 207
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97321-7904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-720-6299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 134 11TH ST
-----------------------------------------------------
City | JEFFERSON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97352-9353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-409-3801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number | 15-2345
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------