Basic Information
| Provider Information | |||||||||
| NPI: | 1457822975 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1789 | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775321789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203633145 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1336 E 101ST AVE | ||||||||
| Address2: | |||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802293970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813463480 | ||||||||
| FaxNumber: | 2814624106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2018 | ||||||||
| LastUpdateDate: | 12/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7203633145 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CSFA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.