Healthcare Provider Details

I. General information

NPI: 1831079110
Provider Name (Legal Business Name): PASADENA WOUND SPECIALTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N LAKE AVE STE 827
PASADENA CA
91101-1849
US

IV. Provider business mailing address

155 N LAKE AVE STE 827
PASADENA CA
91101-1849
US

V. Phone/Fax

Practice location:
  • Phone: 818-326-3037
  • Fax:
Mailing address:
  • Phone: 818-326-3037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NIKITA ELISEEV
Title or Position: CEO
Credential:
Phone: 818-326-3037