MEDICARE: EARL E WOELTJE JR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	122300000X	Dentist

General Provider Information

NPI Number	:	1437664976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EARL E WOELTJE JR

Provider Business Mailing Address
First Line	:	PO BOX 516
Second Line	:
City	:	STREATOR
State	:	IL
Zip	:	61364-0516
Country	:	US
Telephone Number	:	815-672-2195
Fax Number	:

Provider Business Practice Location Address
First Line	:	712 N BLOOMINGTON ST
Second Line	:
City	:	STREATOR
State	:	IL
Zip	:	61364-2087
Country	:	US
Telephone Number	:	815-672-2195
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EARL ERNST WOELTJE JR.
Credential	:	DDS
Telephone Number	:	815-672-2195

Provider Enumeration Date	:	12/06/2017
Last Update Date	:	11/15/2023

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