Healthcare Provider Details

I. General information

NPI: 1235073784
Provider Name (Legal Business Name): LAKE FRONT WOUND CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31501 RANCHO VIEJO RD STE 102
SAN JUAN CAPISTRANO CA
92675-1870
US

IV. Provider business mailing address

2451 PROFESSIONAL CT STE 180
LAS VEGAS NV
89128-0827
US

V. Phone/Fax

Practice location:
  • Phone: 702-344-4996
  • Fax: 702-240-6545
Mailing address:
  • Phone: 702-344-4996
  • Fax: 702-240-6545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SONNY SU
Title or Position: MD
Credential: MD
Phone: 702-338-9500