Healthcare Provider Details

I. General information

NPI: 1548401565
Provider Name (Legal Business Name): WILLIE JAMES WOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2009
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 PACHECO ST
SANTA FE NM
87505-4222
US

IV. Provider business mailing address

1837 KIVA RD
SANTA FE NM
87505-3312
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-2449
  • Fax:
Mailing address:
  • Phone: 505-470-3857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16167
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6431
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: