Healthcare Provider Details

I. General information

NPI: 1609762285
Provider Name (Legal Business Name): WELLO WOUND CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11239 VENTURA BLVD STE 212, UNIT 2
STUDIO CITY CA
91604
US

IV. Provider business mailing address

11413 ETIWANDA AVE
PORTER RANCH CA
91326-2013
US

V. Phone/Fax

Practice location:
  • Phone: 224-425-1142
  • Fax:
Mailing address:
  • Phone: 224-425-1142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROVIN SANTOS
Title or Position: PRINCIPAL PROVIDER AND LEADER
Credential: NP
Phone: 224-425-1142