Basic Information
| Provider Information | |||||||||
| NPI: | 1760141980 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINNESOTA WOUND CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3433 BROADWAY ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554131761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877737 | ||||||||
| FaxNumber: | 7635877069 | ||||||||
| Practice Location | |||||||||
| Address1: | 3433 BROADWAY ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554131761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877737 | ||||||||
| FaxNumber: | 7635877069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2021 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | TUFANO | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO AND TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 4692311545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GERIATRIC SERVICES OF MINNESOTA, LLC | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 7823459 | 05 | MN | MEDICAID |