Provider Demographics
NPI:1740489251
Name:COMPREHENSIVE WOUND CARE
Entity type:Organization
Organization Name:COMPREHENSIVE WOUND CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-706-0174
Mailing Address - Street 1:16515 S 40TH ST
Mailing Address - Street 2:SUITE 139
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0558
Mailing Address - Country:US
Mailing Address - Phone:480-706-0174
Mailing Address - Fax:480-706-0117
Practice Address - Street 1:16515 S 40TH ST
Practice Address - Street 2:SUITE 139
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0558
Practice Address - Country:US
Practice Address - Phone:480-706-0174
Practice Address - Fax:480-706-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ887507Medicaid
AZ=========OtherTAX ID NUMBER