Provider Demographics
NPI:1114740115
Name:PREMIER WOUND CARE OF THE MIDWEST
Entity type:Organization
Organization Name:PREMIER WOUND CARE OF THE MIDWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:573-216-8370
Mailing Address - Street 1:15325 OLD TOWN DR
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64152-1547
Mailing Address - Country:US
Mailing Address - Phone:573-480-8930
Mailing Address - Fax:
Practice Address - Street 1:15325 OLD TOWN DR
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MO
Practice Address - Zip Code:64152-1547
Practice Address - Country:US
Practice Address - Phone:573-480-8930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty