Healthcare Provider Details

I. General information

NPI: 1720761463
Provider Name (Legal Business Name): JUSTICE M WOODS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 BAETEN RD STE C
GREEN BAY WI
54304-4860
US

IV. Provider business mailing address

2826 VIKING DR APT 2A
GREEN BAY WI
54304-5409
US

V. Phone/Fax

Practice location:
  • Phone: 920-857-0410
  • Fax:
Mailing address:
  • Phone: 920-391-1251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number17208-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: