Provider Demographics
NPI:1477613164
Name:WOLTER, CHARLES DENNIS (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DENNIS
Last Name:WOLTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1567
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-1567
Mailing Address - Country:US
Mailing Address - Phone:715-479-9798
Mailing Address - Fax:715-477-0016
Practice Address - Street 1:4340 OTTER LAKE ROAD
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-1567
Practice Address - Country:US
Practice Address - Phone:715-479-9798
Practice Address - Fax:715-477-0016
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1278111N00000X
FL2914111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38824200Medicaid
WI38824200Medicaid