1245402171 NPI number — ERIN E WOLF AU.D., CCC-A

Table of content: ERIN E WOLF AU.D., CCC-A (NPI 1245402171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245402171 NPI number — ERIN E WOLF AU.D., CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLF
Provider First Name:
ERIN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AU.D., CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCORMICK
Provider Other First Name:
ERIN
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245402171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2525 FOX RUN PKWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
YANKTON
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57078-5371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-665-0062
Provider Business Mailing Address Fax Number:
605-665-0076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 N 27TH ST
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68701-4457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-844-8110
Provider Business Practice Location Address Fax Number:
402-844-8113
Provider Enumeration Date:
04/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  262 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10025689600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025689700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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