Provider Demographics
NPI:1427348499
Name:WILDER, HOPI JANE (LAC)
Entity type:Individual
Prefix:MS
First Name:HOPI
Middle Name:JANE
Last Name:WILDER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 442
Mailing Address - Street 2:
Mailing Address - City:HALFWAY
Mailing Address - State:OR
Mailing Address - Zip Code:97834-0442
Mailing Address - Country:US
Mailing Address - Phone:541-406-0615
Mailing Address - Fax:541-972-8646
Practice Address - Street 1:102 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HALFWAY
Practice Address - State:OR
Practice Address - Zip Code:97834-2018
Practice Address - Country:US
Practice Address - Phone:541-406-0615
Practice Address - Fax:541-972-8646
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14586171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist