Healthcare Provider Details

I. General information

NPI: 1508978990
Provider Name (Legal Business Name): WOODBRIDGE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 ANGLING RD
PORTAGE MI
49024-0714
US

IV. Provider business mailing address

5943 STADIUM DR SUITE 3
KALAMAZOO MI
49009-3016
US

V. Phone/Fax

Practice location:
  • Phone: 269-324-8406
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number396814
License Number StateMI

VIII. Authorized Official

Name: BRIJ DEWAN
Title or Position: PRESIDENT
Credential: MD
Phone: 269-385-9900