Provider Demographics
NPI:1801437645
Name:MEDELA WOUND CARE, LLC
Entity type:Organization
Organization Name:MEDELA WOUND CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:FYANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-440-3034
Mailing Address - Street 1:5064 N RAVENCREST LN
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7725
Mailing Address - Country:US
Mailing Address - Phone:801-440-3034
Mailing Address - Fax:
Practice Address - Street 1:2230 N UNIVERSITY PKWY STE 6B
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1584
Practice Address - Country:US
Practice Address - Phone:801-440-3034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty