Provider Demographics
NPI:1417447681
Name:WOOD, MARY LOU G
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:G
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 WEST CARSON STREET
Mailing Address - Street 2:BOX #25
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90509
Mailing Address - Country:US
Mailing Address - Phone:424-338-2710
Mailing Address - Fax:310-533-2210
Practice Address - Street 1:1000 WEST CARSON STREET
Practice Address - Street 2:BOX #25
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90509
Practice Address - Country:US
Practice Address - Phone:424-338-2710
Practice Address - Fax:310-533-2210
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program