=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588471205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELTA WOUND CARE SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 01/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 W SUNFLOWER RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38732-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-290-8765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8622 HOMECOMING DR
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421-8335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-290-8765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BARRY HELMS WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-290-8765
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------