Provider Demographics
NPI:1073841078
Name:WOUND CARE STORE LLC
Entity Type:Organization
Organization Name:WOUND CARE STORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMONSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:321-638-0880
Mailing Address - Street 1:1950 ROCKLEDGE BLVD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3763
Mailing Address - Country:US
Mailing Address - Phone:321-638-0880
Mailing Address - Fax:321-638-2126
Practice Address - Street 1:1950 ROCKLEDGE BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3763
Practice Address - Country:US
Practice Address - Phone:321-638-0880
Practice Address - Fax:321-638-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
FL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier