Healthcare Provider Details

I. General information

NPI: 1699967133
Provider Name (Legal Business Name): LARRY WOODS, OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 WILLOW DR
PLOVER WI
54467-3403
US

IV. Provider business mailing address

2801 WILLOW DR
PLOVER WI
54467-3403
US

V. Phone/Fax

Practice location:
  • Phone: 715-341-5151
  • Fax:
Mailing address:
  • Phone: 715-341-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: LARRY WOODS
Title or Position: OWNER
Credential: OD
Phone: 715-341-5151