Basic Information
| Provider Information | |||||||||
| NPI: | 1205905544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODEN | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MS, PT, OCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 518 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302370518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706318277 | ||||||||
| FaxNumber: | 7706319403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1370 MONTREAL RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300848128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709393566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | GA001221 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.