Provider Demographics
NPI:1093561938
Name:MOBILE WOUND CARE & MULTI-SPECIALTY MEDICAL GROUP
Entity type:Organization
Organization Name:MOBILE WOUND CARE & MULTI-SPECIALTY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-212-1500
Mailing Address - Street 1:1270 S ALFRED ST UNIT 1064
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2506
Mailing Address - Country:US
Mailing Address - Phone:310-212-1500
Mailing Address - Fax:
Practice Address - Street 1:1425 W MANCHESTER AVE STE A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-5436
Practice Address - Country:US
Practice Address - Phone:626-869-6050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty