Provider Demographics
NPI:1700091980
Name:WOLF CREEK ENT LLC
Entity type:Organization
Organization Name:WOLF CREEK ENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-986-6983
Mailing Address - Street 1:1841 N COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2382
Mailing Address - Country:US
Mailing Address - Phone:478-452-3593
Mailing Address - Fax:478-936-9992
Practice Address - Street 1:1841 N COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2382
Practice Address - Country:US
Practice Address - Phone:478-452-3593
Practice Address - Fax:478-936-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
GALDO001648156FX1800X
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA07820OtherSPECTERA
GA100921OtherAVESIS MCAID
GA00897487AMedicaid
GA25391OtherAVESIS
GA=========OtherTAX ID
GA00897487AMedicaid
GA=========OtherBLUE CROSS BLUE SHIELD