Basic Information
| Provider Information | |||||||||
| NPI: | 1386113538 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOUND CARE ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11773 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852480013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809077707 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 E SOUTHERN AVE STE F2 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852827626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806254704 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2018 | ||||||||
| LastUpdateDate: | 11/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | ANAEME | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6026800236 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | AZ | MEDICAID |