Healthcare Provider Details

I. General information

NPI: 1811033921
Provider Name (Legal Business Name): KENNETH LEE WOODSON ATS, CRTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 BARNES RD
ANTIOCH TN
37013-4418
US

IV. Provider business mailing address

945 BARNES RD
ANTIOCH TN
37013-4418
US

V. Phone/Fax

Practice location:
  • Phone: 615-533-1933
  • Fax: 615-834-4782
Mailing address:
  • Phone: 615-533-1933
  • Fax: 615-834-4782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number113486
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: