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General NPI Number Information
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NPI Number | 1750030235
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Entity Type | Organization
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Legal Business Name | RENEUVIA WOUND CARE LLC
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Dates
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Enumeration Date | 03/22/2022
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Last Update Date | 08/15/2023
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Provider Practice Location Address
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Address Line | 1501 WESTPORT RD STE 101
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City | KANSAS CITY
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State | MO
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Zip | 64111-4366
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Country | US
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Telephone | 816-347-8884
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Fax |
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Provider Business Mailing Address
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Address Line | 205 SW CRAIGMONT DR
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City | LEES SUMMIT
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State | MO
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Zip | 64081-1706
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Country | US
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Telephone | 816-347-8884
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRADFORD WALLIS
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Credential |
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Telephone | 816-347-8884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WW0000X
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Taxonomy Name | Wound Care Registered Nurse
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License Number |
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License Number State |
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