Provider Demographics
NPI:1760453716
Name:WOLFF, JEFF LYLE
Entity type:Individual
Prefix:DR
First Name:JEFF
Middle Name:LYLE
Last Name:WOLFF
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 1:622 W GRAND XING
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-2051
Mailing Address - Country:US
Mailing Address - Phone:605-845-5757
Mailing Address - Fax:
Practice Address - Street 1:622 W GRAND XING
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-2051
Practice Address - Country:US
Practice Address - Phone:605-845-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-29
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD710111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7602862Medicaid
SD7602862Medicaid
SDS40613Medicare PIN
SD40614Medicare ID - Type UnspecifiedCHRIROPRACTOR