Provider Demographics
NPI:1659183135
Name:BREEDLOVE WOUND CARE OF OKLAHOMA LLC
Entity type:Organization
Organization Name:BREEDLOVE WOUND CARE OF OKLAHOMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT MANAGER CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-331-2458
Mailing Address - Street 1:PO BOX 1129
Mailing Address - Street 2:
Mailing Address - City:TATUM
Mailing Address - State:TX
Mailing Address - Zip Code:75691-1129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 E TALIAFERRO ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-3410
Practice Address - Country:US
Practice Address - Phone:903-947-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty