Healthcare Provider Details

I. General information

NPI: 1104527597
Provider Name (Legal Business Name): DONALD ALFRED WOODRUFF III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5371 HOLLY RD
BEDFORD HTS OH
44146-1501
US

IV. Provider business mailing address

5371 HOLLY RD
BEDFORD HTS OH
44146-1501
US

V. Phone/Fax

Practice location:
  • Phone: 216-532-4811
  • Fax:
Mailing address:
  • Phone: 216-532-4811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number1828117
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number1848112
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: