Provider Demographics
NPI:1235823121
Name:INTEGRATED WOUND CARE SOUTH CAROLINA LLC
Entity Type:Organization
Organization Name:INTEGRATED WOUND CARE SOUTH CAROLINA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-963-3495
Mailing Address - Street 1:492C CEDAR LN STE 514
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-1713
Mailing Address - Country:US
Mailing Address - Phone:718-963-3495
Mailing Address - Fax:
Practice Address - Street 1:1703 LAUREL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2660
Practice Address - Country:US
Practice Address - Phone:718-963-3495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty