Basic Information
| Provider Information | |||||||||
| NPI: | 1265448401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1963 BETHEL RD SE | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608763393 | ||||||||
| FaxNumber: | 3608950447 | ||||||||
| Practice Location | |||||||||
| Address1: | 1963 BETHEL RD SE | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608763393 | ||||||||
| FaxNumber: | 3608950447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 12/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CH00034426 | WA | Y | Chiropractic Providers | Chiropractor |
No ID Information.