MEDICARE: CAROLINA WOUND CARE AND PHYSICAL THERAPY

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	261QH0100X	Health Service Clinic/Center	P8176	NC
2	261QP2000X	Physical Therapy Clinic/Center	P8176	NC

General Provider Information

NPI Number	:	1245585371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA WOUND CARE AND PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	425 W 24TH ST
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-5035
Country	:	US
Telephone Number	:	336-707-7257
Fax Number	:	336-788-1145

Provider Business Practice Location Address
First Line	:	425 W 24TH ST
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-5035
Country	:	US
Telephone Number	:	336-707-7257
Fax Number	:	336-788-1145

Authorized Official
Title or Position	:	OWNER, PRESIDENT
Name	:	INDIA REID REYNOLDS
Credential	:	PT, CWS, CPC
Telephone Number	:	336-788-1119

Provider Enumeration Date	:	07/15/2012
Last Update Date	:	12/04/2016

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