Provider Demographics
NPI:1962522896
Name:WOFFORD, TEDDY R
Entity type:Individual
Prefix:MR
First Name:TEDDY
Middle Name:R
Last Name:WOFFORD
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 1:3404 E 140TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-4005
Mailing Address - Country:US
Mailing Address - Phone:216-398-5204
Mailing Address - Fax:216-398-5204
Practice Address - Street 1:4527 BROADVIEW RD APT 2
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-4681
Practice Address - Country:US
Practice Address - Phone:440-669-5587
Practice Address - Fax:216-398-5204
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2068211OtherHOME HEALTH PROVIDER