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General NPI Number Information
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NPI Number | 1659183135
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Entity Type | Organization
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Legal Business Name | BREEDLOVE WOUND CARE OF OKLAHOMA LLC
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Dates
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Enumeration Date | 01/22/2025
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 207 E TALIAFERRO ST
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City | MADILL
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State | OK
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Zip | 73446-3410
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Country | US
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Telephone | 903-947-2020
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1129
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City | TATUM
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State | TX
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Zip | 75691-1129
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ASSISTANT MANAGER CREDENTIALING
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Name | ROBERT WILSON
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Credential |
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Telephone | 956-331-2458
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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