Provider Demographics
NPI:1134184559
Name:ALPHA WOUND CARE,LLC
Entity type:Organization
Organization Name:ALPHA WOUND CARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNERLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,RN
Authorized Official - Phone:513-623-0305
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:ROSS
Mailing Address - State:OH
Mailing Address - Zip Code:45061-0485
Mailing Address - Country:US
Mailing Address - Phone:513-623-0305
Mailing Address - Fax:513-738-3038
Practice Address - Street 1:3363 SPYGLASS RDG
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-8404
Practice Address - Country:US
Practice Address - Phone:513-623-0305
Practice Address - Fax:513-738-3038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2244226Medicaid
OH2244226Medicaid
OH9314001Medicare PIN