Basic Information
| Provider Information | |||||||||
| NPI: | 1891087730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 VICTORY DR | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640682395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163132800 | ||||||||
| FaxNumber: | 8167929819 | ||||||||
| Practice Location | |||||||||
| Address1: | 2718 FORUM BLVD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652035451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732564232 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 06/01/2011 | ||||||||
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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 | 237700000X | 2008000939 | MO | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2008000939 | 01 | MO | HEARING INSTRUMENT SPECIALIST | OTHER |