Healthcare Provider Details

I. General information

NPI: 1912209651
Provider Name (Legal Business Name): LISA MARIE WOOD HAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 EAST CITRUS AVE.
REDLANDS CA
92373-5218
US

IV. Provider business mailing address

10455 RIVERSIDE DRIVE
PALM BEACH GARDENS FL
33410-4237
US

V. Phone/Fax

Practice location:
  • Phone: 909-793-2631
  • Fax: 909-792-2413
Mailing address:
  • Phone: 800-323-3277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA2878
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: