Provider Demographics
NPI:1518218379
Name:WOODVIC MEDICAL MANAGEMENT, INC
Entity Type:Organization
Organization Name:WOODVIC MEDICAL MANAGEMENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTLEROAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-988-9825
Mailing Address - Street 1:13653 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1735
Mailing Address - Country:US
Mailing Address - Phone:818-988-9825
Mailing Address - Fax:818-988-9305
Practice Address - Street 1:13653 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1735
Practice Address - Country:US
Practice Address - Phone:818-988-9825
Practice Address - Fax:818-988-9305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74901207R00000X, 208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG74901Medicare UPIN
CAF46669Medicare UPIN