1255755542 NPI number — WOUND CARE ASSOCIATES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255755542 NPI number — WOUND CARE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOUND CARE ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255755542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9816
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33075-0816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-796-7914
Provider Business Mailing Address Fax Number:
954-369-5020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5130 LINTON BLVD STE G1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33484-6597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-330-4695
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
EUGENO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-796-7914

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME0061779 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 120171800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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