Provider Demographics
NPI:1457729345
Name:GREG WOLF
Entity Type:Organization
Organization Name:GREG WOLF
Other - Org Name:GREG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:904-571-5678
Mailing Address - Street 1:1513 CHATHAM CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5050
Mailing Address - Country:US
Mailing Address - Phone:904-571-5678
Mailing Address - Fax:
Practice Address - Street 1:1513 CHATHAM CT
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5050
Practice Address - Country:US
Practice Address - Phone:904-571-5678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health