Provider Demographics
NPI:1750030235
Name:RENEUVIA WOUND CARE LLC
Entity Type:Organization
Organization Name:RENEUVIA WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-347-8884
Mailing Address - Street 1:205 SW CRAIGMONT DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-1706
Mailing Address - Country:US
Mailing Address - Phone:816-347-8884
Mailing Address - Fax:
Practice Address - Street 1:1501 WESTPORT RD STE 101
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-4366
Practice Address - Country:US
Practice Address - Phone:816-347-8884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Single Specialty