Provider Demographics
NPI:1467187963
Name:WOODALL, JAMES ROBERT
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:WOODALL
Suffix:
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 1:4750 BOMONT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN
Mailing Address - State:WV
Mailing Address - Zip Code:25088-9714
Mailing Address - Country:US
Mailing Address - Phone:681-777-1579
Mailing Address - Fax:
Practice Address - Street 1:4750 BOMONT RD
Practice Address - Street 2:
Practice Address - City:GLEN
Practice Address - State:WV
Practice Address - Zip Code:25088-9714
Practice Address - Country:US
Practice Address - Phone:681-777-1579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant