Provider Demographics
NPI:1265892806
Name:WAFER, OLON
Entity type:Individual
Prefix:
First Name:OLON
Middle Name:
Last Name:WAFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 SUTTER WAY APT 202
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-9536
Mailing Address - Country:US
Mailing Address - Phone:928-293-1773
Mailing Address - Fax:
Practice Address - Street 1:1600 BAILEY AVE STE 2
Practice Address - Street 2:
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-3105
Practice Address - Country:US
Practice Address - Phone:760-326-9313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator