Healthcare Provider Details

I. General information

NPI: 1205196094
Provider Name (Legal Business Name): WOODMAN MEDICAL CARE AND CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13653 VICTORY BLVD
VAN NUYS CA
91401-1735
US

IV. Provider business mailing address

13653 VICTORY BLVD
VAN NUYS CA
91401-1735
US

V. Phone/Fax

Practice location:
  • Phone: 818-988-9825
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number00G749010
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number00G749010
License Number StateCA

VIII. Authorized Official

Name: JAMES A HARTLEROAD
Title or Position: OWNER
Credential: MD
Phone: 818-988-9825