Provider Demographics
NPI:1851619357
Name:WULF CLINIC HEALTHCARE PA
Entity Type:Organization
Organization Name:WULF CLINIC HEALTHCARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WULF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:479-271-9191
Mailing Address - Street 1:593 HORSEBARN RD.
Mailing Address - Street 2:STE. 101
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8797
Mailing Address - Country:US
Mailing Address - Phone:479-271-9191
Mailing Address - Fax:479-271-9196
Practice Address - Street 1:593 HORSEBARN RD
Practice Address - Street 2:STE. 101
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8797
Practice Address - Country:US
Practice Address - Phone:479-271-9191
Practice Address - Fax:479-271-9196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-07
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR111N00000X, 225100000X, 363L00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6576900001Medicare NSC