Provider Demographics
NPI:1235414905
Name:SOUTHWEST WOUND CENTER LLC
Entity Type:Organization
Organization Name:SOUTHWEST WOUND CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-258-6200
Mailing Address - Street 1:340 W 32ND ST
Mailing Address - Street 2:# 547
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8128
Mailing Address - Country:US
Mailing Address - Phone:619-258-6200
Mailing Address - Fax:
Practice Address - Street 1:1501 W 24TH ST
Practice Address - Street 2:#205
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6370
Practice Address - Country:US
Practice Address - Phone:928-344-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST EMERGENCY PHYSICIANS, P.L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4064207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty