MEDICARE: LAS VEGAS WOUND CARE CLINIC LLC

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	261QP2300X	Primary Care Clinic/Center
2	163WW0000X	Wound Care Registered Nurse

General Provider Information

NPI Number	:	1326883174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAS VEGAS WOUND CARE CLINIC LLC

Provider Business Mailing Address
First Line	:	2855 S BRONCO ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5207
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2855 S BRONCO ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5207
Country	:	US
Telephone Number	:	470-363-3311
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	EDSEL IWAY
Credential	:	MD
Telephone Number	:	470-363-3311

Provider Enumeration Date	:	06/25/2024
Last Update Date	:	06/25/2024

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