Healthcare Provider Details

I. General information

NPI: 1801773064
Provider Name (Legal Business Name): WOUND100 FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20809 NW 17TH ST
PEMBROKE PINES FL
33029-2304
US

IV. Provider business mailing address

17414 WASHINGTON ST
OMAHA NE
68135-3202
US

V. Phone/Fax

Practice location:
  • Phone: 561-400-5303
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LEAH FORD
Title or Position: CORPORATE MEDICAL OFFICER
Credential: DPM
Phone: 561-400-5303