=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376363291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMENITY WOUND CARE SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2024
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 CHAMBLEE TUCKER RD BLDG 14
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30341-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-365-6358
-----------------------------------------------------
Fax | 855-552-3776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 CHAMBLEE TUCKER RD BLDG 14
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30341-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-365-6358
-----------------------------------------------------
Fax | 855-552-3776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | LISA MERKOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-800-9958
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WW0000X
-----------------------------------------------------
Taxonomy Name | Wound Care Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------