Healthcare Provider Details

I. General information

NPI: 1982242434
Provider Name (Legal Business Name): ASHLEY WOOD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12945 MARENGO RD
GALT CA
95632-8422
US

IV. Provider business mailing address

12945 MARENGO RD
GALT CA
95632-8422
US

V. Phone/Fax

Practice location:
  • Phone: 209-744-4250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberBOC270768
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: