Provider Demographics
NPI:1467485813
Name:PRO-ACTIVE WOUND CARE CLINICS LLC
Entity Type:Organization
Organization Name:PRO-ACTIVE WOUND CARE CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOOGENDOORN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:614-366-3838
Mailing Address - Street 1:5920 WILCOX PL
Mailing Address - Street 2:SUITE E
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-6802
Mailing Address - Country:US
Mailing Address - Phone:614-336-3838
Mailing Address - Fax:614-336-3933
Practice Address - Street 1:5920 WILCOX PL
Practice Address - Street 2:SUITE E
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-6802
Practice Address - Country:US
Practice Address - Phone:614-336-3838
Practice Address - Fax:614-336-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2468986Medicaid
OH2468986Medicaid
OH5052040001Medicare NSC