Healthcare Provider Details

I. General information

NPI: 1962392753
Provider Name (Legal Business Name): STEVEN WOOLLEY 68W
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 WILLIAMS WAY 232D MED BN E40-25
JBSA FT SAM HOUSTON TX
78234
US

IV. Provider business mailing address

405 COLUMBIA CIR
BOSSIER CITY LA
71112-4268
US

V. Phone/Fax

Practice location:
  • Phone: 318-655-7869
  • Fax:
Mailing address:
  • Phone: 318-655-7869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: