Healthcare Provider Details

I. General information

NPI: 1124563564
Provider Name (Legal Business Name): WOODBURY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9891 IRVINE CENTER DR SUITE 200
IRVINE CA
92618-4317
US

IV. Provider business mailing address

9891 IRVINE CENTER DR SUITE 200
IRVINE CA
92618-4317
US

V. Phone/Fax

Practice location:
  • Phone: 949-232-1988
  • Fax: 949-232-1983
Mailing address:
  • Phone: 949-232-1988
  • Fax: 949-232-1983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN CONSTABLE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 949-232-1988