Provider Demographics
NPI:1457830804
Name:FANTASTIC WOUND CARE INC
Entity Type:Organization
Organization Name:FANTASTIC WOUND CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PART OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLAYEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OSIYEMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-725-4100
Mailing Address - Street 1:2580 METROCENTRE BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3100
Mailing Address - Country:US
Mailing Address - Phone:561-725-4100
Mailing Address - Fax:
Practice Address - Street 1:2580 METROCENTRE BLVD STE 6
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3100
Practice Address - Country:US
Practice Address - Phone:561-602-9988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261Q00000X, 261QI0500X, 261QI0500X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion TherapyGroup - Multi-Specialty