=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144971615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOUND MEDIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2022
-----------------------------------------------------
Last Update Date | 10/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4408 MESQUITE TERRACE DR
-----------------------------------------------------
City | MANVEL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77578-1576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-354-2920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4205 BROADWAY ST STE 221
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77581-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-491-8168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIZEL YUKEE
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 407-619-4931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------