Provider Demographics
NPI:1619305612
Name:WOODS, LONNIE
Entity Type:Individual
Prefix:
First Name:LONNIE
Middle Name:
Last Name:WOODS
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 1:914 BELCLAIRE CIR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-1238
Mailing Address - Country:US
Mailing Address - Phone:214-277-9516
Mailing Address - Fax:972-291-0032
Practice Address - Street 1:5025 E BERRY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-2239
Practice Address - Country:US
Practice Address - Phone:217-277-9516
Practice Address - Fax:214-277-9516
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75-2515490311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home