Healthcare Provider Details

I. General information

NPI: 1235414905
Provider Name (Legal Business Name): SOUTHWEST WOUND CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W 24TH ST #205
YUMA AZ
85364-6370
US

IV. Provider business mailing address

340 W 32ND ST # 547
YUMA AZ
85364-8128
US

V. Phone/Fax

Practice location:
  • Phone: 928-344-2000
  • Fax:
Mailing address:
  • Phone: 619-258-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number4064
License Number StateAZ

VIII. Authorized Official

Name: MATTHEW DICKSON
Title or Position: PRESIDENT
Credential: DO
Phone: 619-258-6200