Provider Demographics
NPI:1578681946
Name:WOODLAKE VILLAGE PEDIATRICS LLC
Entity Type:Organization
Organization Name:WOODLAKE VILLAGE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-639-0717
Mailing Address - Street 1:14732 VILLAGE SQUARE PLACE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2253
Mailing Address - Country:US
Mailing Address - Phone:804-639-0717
Mailing Address - Fax:804-639-0767
Practice Address - Street 1:14732 VILLAGE SQUARE PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2253
Practice Address - Country:US
Practice Address - Phone:804-639-0717
Practice Address - Fax:804-639-0767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056329174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty