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General NPI Number Information
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NPI Number | 1992323216
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Entity Type | Organization
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Legal Business Name | WOLF PACK LLC
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Dates
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Enumeration Date | 07/13/2020
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Last Update Date | 07/13/2020
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Provider Practice Location Address
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Address Line | 939 S 25TH E STE 115
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City | AMMON
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State | ID
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Zip | 83406-5736
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Country | US
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Telephone | 208-523-1209
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Fax |
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Provider Business Mailing Address
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Address Line | 939 S 25TH E STE 115
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City | AMMON
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State | ID
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Zip | 83406-5736
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Country | US
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Telephone | 208-523-1209
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SHAWN TOLMAN
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Credential |
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Telephone | 208-313-1089
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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 |
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License Number State |
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