Provider Demographics
NPI:1689417206
Name:PROVIDENCE WOUND CARE LLC
Entity type:Organization
Organization Name:PROVIDENCE WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:OSITADINMA
Authorized Official - Last Name:NWADEYI
Authorized Official - Suffix:
Authorized Official - Credentials:DRPH, PA-C
Authorized Official - Phone:214-315-5255
Mailing Address - Street 1:4011 HARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-5165
Mailing Address - Country:US
Mailing Address - Phone:214-315-5255
Mailing Address - Fax:346-571-3129
Practice Address - Street 1:9100 SOUTHWEST FWY STE 206
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1531
Practice Address - Country:US
Practice Address - Phone:214-315-5255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty