Healthcare Provider Details

I. General information

NPI: 1114635174
Provider Name (Legal Business Name): WOUND COMPANY PROVIDER GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 DREW AVE S
MINNEAPOLIS MN
55416-3646
US

IV. Provider business mailing address

2240 DREW AVE S
MINNEAPOLIS MN
55416-3646
US

V. Phone/Fax

Practice location:
  • Phone: 858-774-6305
  • Fax:
Mailing address:
  • Phone: 858-774-6305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC2100X
TaxonomyContinence Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WE0900X
TaxonomyEnterostomal Therapy Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DR. BRANTLEY TILMAN JOLLY JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 703-447-6897