Provider Demographics
NPI:1780866525
Name:WOODVILLE PROFESSIONAL HEALTHCARE LLC
Entity Type:Organization
Organization Name:WOODVILLE PROFESSIONAL HEALTHCARE LLC
Other - Org Name:FREMONT CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TY
Authorized Official - Middle Name:N
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-334-7737
Mailing Address - Street 1:444 N STONE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-1530
Mailing Address - Country:US
Mailing Address - Phone:419-334-7737
Mailing Address - Fax:419-334-2828
Practice Address - Street 1:444 N STONE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-1530
Practice Address - Country:US
Practice Address - Phone:419-334-7737
Practice Address - Fax:419-334-2828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2805111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000362532OtherANTHEM BCBS
OH=========-00OtherWORKERS COMP
OH=========-00OtherWORKERS COMP