=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356067375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST COAST WOUND CARE SPECIALISTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2022
-----------------------------------------------------
Last Update Date | 08/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4407 24TH AVE E
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-6343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-599-1837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4407 24TH AVE E
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-6343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-933-0223
-----------------------------------------------------
Fax | 833-464-5076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRISTI CAY KITA
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 941-933-0223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------