Healthcare Provider Details

I. General information

NPI: 1457830804
Provider Name (Legal Business Name): FANTASTIC WOUND CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 METROCENTRE BLVD STE 6
WEST PALM BEACH FL
33407-3100
US

IV. Provider business mailing address

2580 METROCENTRE BLVD STE 6
WEST PALM BEACH FL
33407-3100
US

V. Phone/Fax

Practice location:
  • Phone: 561-602-9988
  • Fax:
Mailing address:
  • Phone: 561-725-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. OLAYEMI OSIYEMI
Title or Position: PRESIDENT/PART OWNER
Credential: MD
Phone: 561-725-4100