Healthcare Provider Details

I. General information

NPI: 1629054051
Provider Name (Legal Business Name): HENRY WOODRUFF PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 827 BOX 1000
FPO AE
09617
IT

IV. Provider business mailing address

PSC 827 BOX 1000
FPO AE
09617
IT

V. Phone/Fax

Practice location:
  • Phone: 390818114676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number9844-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: