Provider Demographics
NPI:1265929012
Name:FANTASTIC WOUND CARE LLC
Entity type:Organization
Organization Name:FANTASTIC WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OLAYEMI
Authorized Official - Middle Name:OLAJIDE
Authorized Official - Last Name:OSLYEMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-602-9988
Mailing Address - Street 1:2580 METROCENTRE BOULEVARD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407
Mailing Address - Country:US
Mailing Address - Phone:561-602-9988
Mailing Address - Fax:
Practice Address - Street 1:2580 METROCENTRE BOULEVARD
Practice Address - Street 2:SUITE 5
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407
Practice Address - Country:US
Practice Address - Phone:561-602-9988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Single Specialty
No163WX1500XNursing Service ProvidersRegistered NurseOstomy CareGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology