Provider Demographics
NPI:1811033921
Name:WOODSON, KENNETH LEE (ATS, CRTS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:WOODSON
Suffix:
Gender:M
Credentials:ATS, CRTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4418
Mailing Address - Country:US
Mailing Address - Phone:615-533-1933
Mailing Address - Fax:615-834-4782
Practice Address - Street 1:945 BARNES RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-4418
Practice Address - Country:US
Practice Address - Phone:615-533-1933
Practice Address - Fax:615-834-4782
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN113486171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN00E52OtherDMRS PROVIDER #
TN00E40OtherDMRS PROVIDER #