Healthcare Provider Details

I. General information

NPI: 1649002734
Provider Name (Legal Business Name): MOBILE WOUND CARE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E WISCONSIN AVE STE 1925
MILWAUKEE WI
53202-4825
US

IV. Provider business mailing address

111 E WISCONSIN AVE STE 1705
MILWAUKEE WI
53202-4811
US

V. Phone/Fax

Practice location:
  • Phone: 414-323-0260
  • Fax:
Mailing address:
  • Phone: 414-323-0260
  • 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 Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: TYLER STOUT
Title or Position: MANAGER
Credential:
Phone: 337-315-7927