Provider Demographics
NPI:1053735845
Name:WOODS, LARRY
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WOODS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LOGANBERRY LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-4693
Mailing Address - Country:US
Mailing Address - Phone:865-643-8666
Mailing Address - Fax:
Practice Address - Street 1:400 LOGANBERRY LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-4693
Practice Address - Country:US
Practice Address - Phone:865-643-8666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0283123172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0283123OtherKNOX COUNTY, TN BUSINESS LICENSE