Provider Demographics
NPI:1164862371
Name:ST PEREGRINE WOUND CARE LLC
Entity Type:Organization
Organization Name:ST PEREGRINE WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-371-6244
Mailing Address - Street 1:9551 W COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85373-1725
Mailing Address - Country:US
Mailing Address - Phone:605-371-6244
Mailing Address - Fax:
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2443
Practice Address - Country:US
Practice Address - Phone:602-246-5576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)