Provider Demographics
NPI:1194017426
Name:OUTPATIENT WOUND SOLUTIONS, INC.
Entity Type:Organization
Organization Name:OUTPATIENT WOUND SOLUTIONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MICHALUK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:707-999-0242
Mailing Address - Street 1:607 ELMIRA RD
Mailing Address - Street 2:SUITE 165
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4655
Mailing Address - Country:US
Mailing Address - Phone:707-999-0242
Mailing Address - Fax:
Practice Address - Street 1:607 ELMIRA RD
Practice Address - Street 2:SUITE 165
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4655
Practice Address - Country:US
Practice Address - Phone:707-999-0242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7618939Medicaid
CAEG268ZMedicare PIN