Provider Demographics
NPI:1336347558
Name:WOLFE, RANDALL D
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:D
Last Name:WOLFE
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 1:500 ST. ANTHONY STREET
Mailing Address - Street 2:P. O. BOX 308
Mailing Address - City:LAKIN
Mailing Address - State:KS
Mailing Address - Zip Code:67860-0308
Mailing Address - Country:US
Mailing Address - Phone:620-355-7754
Mailing Address - Fax:
Practice Address - Street 1:500 ST. ANTHONY STREET
Practice Address - Street 2:
Practice Address - City:LAKIN
Practice Address - State:KS
Practice Address - Zip Code:67860-0308
Practice Address - Country:US
Practice Address - Phone:620-355-7754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200005960AMedicaidPROVIDER NUMBER