MEDICARE: LAKE FRONT WOUND CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1235073784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE FRONT WOUND CARE

Provider Business Mailing Address
First Line	:	2451 PROFESSIONAL CT STE 180
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0827
Country	:	US
Telephone Number	:	702-344-4996
Fax Number	:	702-240-6545

Provider Business Practice Location Address
First Line	:	31501 RANCHO VIEJO RD STE 102
Second Line	:
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-1870
Country	:	US
Telephone Number	:	702-344-4996
Fax Number	:	702-240-6545

Authorized Official
Title or Position	:	MD
Name	:	SONNY SU
Credential	:	MD
Telephone Number	:	702-338-9500

Provider Enumeration Date	:	04/15/2026
Last Update Date	:	04/15/2026

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Directions to “LAKE FRONT WOUND CARE ” Practice Location

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