Healthcare Provider Details

I. General information

NPI: 1417921099
Provider Name (Legal Business Name): LAWRENCE ALBERT WOOD V DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 VILLAGE EDGE DR
BRODHEADSVILLE PA
18322
US

IV. Provider business mailing address

307 VILLAGE EDGE DR
BRODHEADSVILLE PA
18322-7715
US

V. Phone/Fax

Practice location:
  • Phone: 570-992-1011
  • Fax: 570-402-3534
Mailing address:
  • Phone: 570-992-1011
  • Fax: 570-402-3534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC009149
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCR1415
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: