Provider Demographics
NPI:1629044110
Name:WOUND CARE CLINIC-TN, INC.
Entity Type:Organization
Organization Name:WOUND CARE CLINIC-TN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-236-2600
Mailing Address - Street 1:1910 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5806
Mailing Address - Country:US
Mailing Address - Phone:870-236-2600
Mailing Address - Fax:870-236-3314
Practice Address - Street 1:1910 MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5806
Practice Address - Country:US
Practice Address - Phone:870-236-2600
Practice Address - Fax:870-236-3314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARQ11420Medicare UPIN