Provider Demographics
NPI:1154319408
Name:WOUND CARE CLINIC - ESU, INC.
Entity Type:Organization
Organization Name:WOUND CARE CLINIC - ESU, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:KREISSLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-272-9494
Mailing Address - Street 1:PO BOX 9910
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31412-0110
Mailing Address - Country:US
Mailing Address - Phone:912-272-9494
Mailing Address - Fax:912-998-0041
Practice Address - Street 1:1000 TOWNE CENTER BLVD
Practice Address - Street 2:SUITE 705
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4052
Practice Address - Country:US
Practice Address - Phone:912-272-9494
Practice Address - Fax:912-998-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA559348415AMedicaid
Y30608Medicare UPIN
GA559348415AMedicaid
GAGRP7434Medicare ID - Type Unspecified