1295104396 NPI number — WOUND CARE CENTER AT GLASGOW

Table of content: (NPI 1295104396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295104396 NPI number — WOUND CARE CENTER AT GLASGOW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOUND CARE CENTER AT GLASGOW
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:
WOUND CARE CENTER AT GLASGOW
Provider Other Organization Name Type Code:
3
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:
1295104396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
507 S L ROGERS WELLS BLVD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
GLASGOW
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42141-1043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-629-2273
Provider Business Mailing Address Fax Number:
270-629-2278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 S L ROGERS WELLS BLVD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
GLASGOW
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42141-1043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-629-2273
Provider Business Practice Location Address Fax Number:
270-629-2278
Provider Enumeration Date:
09/18/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FRANKLIN
Authorized Official First Name:
VIVIAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
APRN
Authorized Official Telephone Number:
270-629-2273

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K184430 . This is a "MEDICARE PTAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100578180 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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