Provider Demographics
NPI:1811170442
Name:DR JOHN A WOOD DC PS
Entity type:Organization
Organization Name:DR JOHN A WOOD DC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-630-9395
Mailing Address - Street 1:11027 SE KENT KANGLEY RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7205
Mailing Address - Country:US
Mailing Address - Phone:253-630-9395
Mailing Address - Fax:253-639-2219
Practice Address - Street 1:11027 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7205
Practice Address - Country:US
Practice Address - Phone:253-630-9395
Practice Address - Fax:253-639-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2460261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2012235Medicaid
WA8405029Medicaid
WA2012235Medicaid
WA2012235Medicaid
WAGAB21434Medicare PIN
WA69518Medicare UPIN