Healthcare Provider Details

I. General information

NPI: 1265929012
Provider Name (Legal Business Name): FANTASTIC WOUND CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 METROCENTRE BOULEVARD SUITE 5
WEST PALM BEACH FL
33407
US

IV. Provider business mailing address

2580 METROCENTRE BOULEVARD SUITE 5
WEST PALM BEACH FL
33407
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WX1500X
TaxonomyOstomy Care Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. OLAYEMI OLAJIDE OSLYEMI
Title or Position: PRESIDENT
Credential: M.D
Phone: 561-602-9988