Basic Information
| Provider Information | |||||||||
| NPI: | 1821194275 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE WOUND CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 1115 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173515 | ||||||||
| FaxNumber: | 4345724952 | ||||||||
| Practice Location | |||||||||
| Address1: | 2232 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173914 | ||||||||
| FaxNumber: | 4345173912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAZELWOOD | ||||||||
| AuthorizedOfficialFirstName: | CECIL | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4345173515 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.