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General NPI Number Information
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NPI Number | 1801187083
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Entity Type | Organization
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Legal Business Name | LAURIE M. WOLL D.O.
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Dates
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Enumeration Date | 04/22/2011
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Last Update Date | 04/22/2011
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Provider Practice Location Address
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Address Line | 9301 CENTRAL AVE STE 201
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City | MONTCLAIR
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State | CA
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Zip | 91763-2446
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Country | US
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Telephone | 909-625-5567
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Fax | 909-621-4900
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Provider Business Mailing Address
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Address Line | 9301 CENTRAL AVE., SUITE 201
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City | MONTCLAIR
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State | CA
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Zip | 91763
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Country | US
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Telephone | 909-625-5567
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Fax | 909-621-4900
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | SHANNON A SEHNE
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Credential |
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Telephone | 909-625-5567
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA17704
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License Number State | CA
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