Healthcare Provider Details

I. General information

NPI: 1578219630
Provider Name (Legal Business Name): ADVANCED HOME WOUND CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 02/28/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4223 YACHT HARBOR DR
STOCKTON CA
95204-1123
US

IV. Provider business mailing address

4223 YACHT HARBOR DR
STOCKTON CA
95204-1123
US

V. Phone/Fax

Practice location:
  • Phone: 310-944-1912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSHUA BOYD STAUFFER
Title or Position: OWNER
Credential: DPM
Phone: 310-944-1912