Provider Demographics
NPI:1083953731
Name:WOODKE, KELLY ROY SR (MR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROY
Last Name:WOODKE
Suffix:SR
Gender:M
Credentials:MR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 KOURT DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-2278
Mailing Address - Country:US
Mailing Address - Phone:541-232-0146
Mailing Address - Fax:
Practice Address - Street 1:515 KOURT DR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-2278
Practice Address - Country:US
Practice Address - Phone:541-232-0146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12029225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist