1649614082 NPI number — JUSTIN CHARLES WOODS

Table of content: JUSTIN CHARLES WOODS (NPI 1649614082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649614082 NPI number — JUSTIN CHARLES WOODS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODS
Provider First Name:
JUSTIN
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649614082
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORTSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31808-0370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
706-494-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4689 US HIGHWAY 17 STE 12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLEMING ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32003-4831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
43-759-7539
Provider Business Practice Location Address Fax Number:
904-375-8380
Provider Enumeration Date:
04/27/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  ME141406 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0801X , with the licence number: ME141406 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: XEI0G . This is a "FL BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 103539300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: LK096 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 103539300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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