Provider Demographics
NPI:1225103898
Name:IMPLEXUS WOUND CARE SERVICE LLC
Entity Type:Organization
Organization Name:IMPLEXUS WOUND CARE SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WOLLHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD WCC
Authorized Official - Phone:920-261-4069
Mailing Address - Street 1:1911 GATEWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094
Mailing Address - Country:US
Mailing Address - Phone:920-261-4069
Mailing Address - Fax:
Practice Address - Street 1:1911 GATEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094
Practice Address - Country:US
Practice Address - Phone:920-261-4069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20951020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1023435OtherENTITY ID NUMBER FOR ARTI