Provider Demographics
NPI:1205374493
Name:AT HOME WOUNDCARE INC
Entity Type:Organization
Organization Name:AT HOME WOUNDCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALONZO
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:213-793-6545
Mailing Address - Street 1:13166 NW 11TH PL
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2958
Mailing Address - Country:US
Mailing Address - Phone:347-563-6066
Mailing Address - Fax:
Practice Address - Street 1:13166 NW 11TH PL
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2958
Practice Address - Country:US
Practice Address - Phone:347-563-6066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122443174400000X
207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIC7762Medicare UPIN
FLHQ549ZMedicare UPIN
FLIH7092Medicare UPIN