MEDICARE: WOODWARD AVE., LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1568752202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODWARD AVE., LLC

Provider Business Mailing Address
First Line	:	9920 W CHEYENNE AVE
Second Line	:	SUITE 120
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7725
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9920 W CHEYENNE AVE
Second Line	:	SUITE 120
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7725
Country	:	US
Telephone Number	:	702-316-2281
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. MATT PAXTON
Credential	:
Telephone Number	:	702-316-2281

Provider Enumeration Date	:	04/14/2011
Last Update Date	:	04/14/2011

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Directions to “WOODWARD AVE., LLC ” Practice Location

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