1700643533 NPI number — TEXAS WOUND CARE MED 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 1700643533 NPI number — TEXAS WOUND CARE MED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS WOUND CARE MED 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:
1700643533
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6090 SURETY DR STE 420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79905-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-303-9215
Provider Business Mailing Address Fax Number:
915-218-6518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1387 GEORGE DIETER DR STE D105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79936-7410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-994-7700
Provider Business Practice Location Address Fax Number:
915-218-6518
Provider Enumeration Date:
02/28/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PENA
Authorized Official First Name:
JOANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
512-994-7700

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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