Healthcare Provider Details

I. General information

NPI: 1487336863
Provider Name (Legal Business Name): SOUTHWEST FLORIDA MOBILE WOUND CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21208 WAYMOUTH RUN
ESTERO FL
33928-3243
US

IV. Provider business mailing address

21208 WAYMOUTH RUN
ESTERO FL
33928-3243
US

V. Phone/Fax

Practice location:
  • Phone: 401-256-9997
  • Fax: 239-361-2780
Mailing address:
  • Phone: 401-256-9997
  • Fax: 239-361-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MEKAAEL MAHMOUD
Title or Position: MANAGING MEMBER
Credential: OTR/L
Phone: 239-214-9842