Healthcare Provider Details

I. General information

NPI: 1396487013
Provider Name (Legal Business Name): ELITE WOUND CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 09/24/2022
Certification Date: 09/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8660 E 103RD ST
TULSA OK
74133-6982
US

IV. Provider business mailing address

8660 E 103RD ST
TULSA OK
74133-6982
US

V. Phone/Fax

Practice location:
  • Phone: 918-970-6194
  • Fax: 918-970-6194
Mailing address:
  • Phone: 918-830-0059
  • Fax: 918-970-6194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DARNELL E. BLACKMON
Title or Position: OWNER
Credential: MD
Phone: 918-830-0059