Provider Demographics
NPI:1760141980
Name:MINNESOTA WOUND CARE LLC
Entity Type:Organization
Organization Name:MINNESOTA WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUFANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-231-1545
Mailing Address - Street 1:3433 BROADWAY ST NE STE 300
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1761
Mailing Address - Country:US
Mailing Address - Phone:763-587-7737
Mailing Address - Fax:763-587-7069
Practice Address - Street 1:3433 BROADWAY ST NE STE 300
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1761
Practice Address - Country:US
Practice Address - Phone:763-587-7737
Practice Address - Fax:763-587-7069
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GERIATRIC SERVICES OF MINNESOTA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7823459Medicaid