Healthcare Provider Details

I. General information

NPI: 1023543519
Provider Name (Legal Business Name): WOODS FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2017
Last Update Date: 06/22/2024
Certification Date: 06/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20652 N 53RD AVE
GLENDALE AZ
85308-9309
US

IV. Provider business mailing address

20652 N 53RD AVE
GLENDALE AZ
85308-9309
US

V. Phone/Fax

Practice location:
  • Phone: 262-383-5517
  • Fax: 920-268-4285
Mailing address:
  • Phone: 262-383-5517
  • Fax: 920-268-4285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN WOODS
Title or Position: OWNER
Credential: MD
Phone: 262-383-5517