Provider Demographics
NPI:1073116661
Name:WOODARD, STEVIE THOMAS (CEO/DIRECTOR)
Entity Type:Individual
Prefix:
First Name:STEVIE
Middle Name:THOMAS
Last Name:WOODARD
Suffix:
Gender:M
Credentials:CEO/DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37011-1008
Mailing Address - Country:US
Mailing Address - Phone:615-635-3228
Mailing Address - Fax:615-523-2104
Practice Address - Street 1:2585 KANLOW DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3951
Practice Address - Country:US
Practice Address - Phone:615-635-3228
Practice Address - Fax:615-523-2104
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10000000270963747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider