Provider Demographics
NPI:1023343571
Name:WOODVIC MEDICAL CARE AND CLINIC, CORP
Entity type:Organization
Organization Name:WOODVIC MEDICAL CARE AND CLINIC, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROLEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-988-9825
Mailing Address - Street 1:13653 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1735
Mailing Address - Country:US
Mailing Address - Phone:818-988-9825
Mailing Address - Fax:
Practice Address - Street 1:13653 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1735
Practice Address - Country:US
Practice Address - Phone:818-988-9825
Practice Address - Fax:818-988-9305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-15
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF96355Medicare UPIN