MEDICARE: MR. WOODROW WILSON HAMMOND III MPT

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	225100000X	Physical Therapist	37201	CA

General Provider Information

NPI Number	:	1417253808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WOODROW WILSON HAMMOND III MPT

Provider Business Mailing Address
First Line	:	626 WOODWORTH ST
Second Line	:
City	:	SAN FERNANDO
State	:	CA
Zip	:	91340-4217
Country	:	US
Telephone Number	:	915-861-4647
Fax Number	:

Provider Business Practice Location Address
First Line	:	626 WOODWORTH ST
Second Line	:
City	:	SAN FERNANDO
State	:	CA
Zip	:	91340-4217
Country	:	US
Telephone Number	:	915-861-4647
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2011
Last Update Date	:	02/01/2011

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