Provider Demographics
NPI:1922074491
Name:WOUND CARE CLINIC ESU INC
Entity Type:Organization
Organization Name:WOUND CARE CLINIC ESU 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:731-287-0804
Mailing Address - Street 1:509 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3877
Mailing Address - Country:US
Mailing Address - Phone:731-287-0804
Mailing Address - Fax:731-287-7373
Practice Address - Street 1:509 LAKE RD
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3877
Practice Address - Country:US
Practice Address - Phone:731-287-0804
Practice Address - Fax:731-287-7373
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?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP78929Medicare UPIN
P13940Medicare UPIN
ARQ11420Medicare UPIN