Provider Demographics
NPI:1992323216
Name:WOLF PACK LLC
Entity type:Organization
Organization Name:WOLF PACK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-313-1089
Mailing Address - Street 1:939 S 25TH E STE 115
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-5736
Mailing Address - Country:US
Mailing Address - Phone:208-523-1209
Mailing Address - Fax:
Practice Address - Street 1:939 S 25TH E STE 115
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-5736
Practice Address - Country:US
Practice Address - Phone:208-523-1209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center