Provider Demographics
NPI:1174261119
Name:WOODFORK, PRENTISS L JR
Entity Type:Individual
Prefix:
First Name:PRENTISS
Middle Name:L
Last Name:WOODFORK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8326 MAIN ST BLDG 3
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-4871
Mailing Address - Country:US
Mailing Address - Phone:985-868-2620
Mailing Address - Fax:985-868-8547
Practice Address - Street 1:8326 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-4871
Practice Address - Country:US
Practice Address - Phone:985-868-2620
Practice Address - Fax:985-868-8547
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator