Basic Information
| Provider Information | |||||||||
| NPI: | 1902443609 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANO PCP WOUND CARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WOUND HEALING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9725 NW 117TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MEDLEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331781260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545149360 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9725 NW 117TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MEDLEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331781260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545149360 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2019 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | MARLOW | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9545149360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.