MEDICARE: WOODVIC MEDICAL CARE AND CLINIC, CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1023343571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODVIC MEDICAL CARE AND CLINIC, CORP

Provider Business Mailing Address
First Line	:	13653 VICTORY BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-1735
Country	:	US
Telephone Number	:	818-988-9825
Fax Number	:

Provider Business Practice Location Address
First Line	:	13653 VICTORY BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-1735
Country	:	US
Telephone Number	:	818-988-9825
Fax Number	:	818-988-9305

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ALLA KOROLEVA
Credential	:
Telephone Number	:	818-988-9825

Provider Enumeration Date	:	10/15/2009
Last Update Date	:	02/22/2010

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