Healthcare Provider Details

I. General information

NPI: 1669296364
Provider Name (Legal Business Name): WOUND CARE OF WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/21/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 GATEWAY DR
WAUPUN WI
53963-2276
US

IV. Provider business mailing address

160 GATEWAY DR
WAUPUN WI
53963-2276
US

V. Phone/Fax

Practice location:
  • Phone: 920-324-9899
  • Fax:
Mailing address:
  • Phone: 920-324-9899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RANDALL BLOHOWIAK
Title or Position: OWNER
Credential: DC
Phone: 920-324-9899