Provider Demographics
NPI:1275924441
Name:WOOD HEALTH CARE CLINIC LAB
Entity Type:Organization
Organization Name:WOOD HEALTH CARE CLINIC LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-845-2893
Mailing Address - Street 1:1307 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-2316
Mailing Address - Country:US
Mailing Address - Phone:304-845-2893
Mailing Address - Fax:304-845-2624
Practice Address - Street 1:1307 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-2316
Practice Address - Country:US
Practice Address - Phone:304-845-2893
Practice Address - Fax:304-845-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51D0235758291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0008910001Medicaid