=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982941936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONAL TELEWOUND CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2013
-----------------------------------------------------
Last Update Date | 01/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2015 GUM BRANCH RD 624
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28540-4583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-371-2204
-----------------------------------------------------
Fax | 877-210-5143
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 374 OSPREY PT
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30087-6163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-371-2204
-----------------------------------------------------
Fax | 877-210-5143
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | DIANE ALEXANDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-371-2204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------