=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740772185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGEL M WOOD CDL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2018
-----------------------------------------------------
Last Update Date | 06/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 347 MIDWAY BLVD
-----------------------------------------------------
City | ELYRIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-271-0563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2710 STATE RD
-----------------------------------------------------
City | VERMILION
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44089-9109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------