Healthcare Provider Details

I. General information

NPI: 1275167405
Provider Name (Legal Business Name): LORI WOIWODE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 COLLEGE DR STE 106
BISMARCK ND
58501-1207
US

IV. Provider business mailing address

1110 COLLEGE DR STE 106
BISMARCK ND
58501-1207
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-1208
  • Fax:
Mailing address:
  • Phone: 701-751-1208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number801
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: