Provider Demographics
NPI:1316705361
Name:FIRST SOURCE WOUND CARE
Entity type:Organization
Organization Name:FIRST SOURCE WOUND CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BROKISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-850-3114
Mailing Address - Street 1:1540 KELLER PKWY STE 108-168
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3686
Mailing Address - Country:US
Mailing Address - Phone:469-850-3114
Mailing Address - Fax:
Practice Address - Street 1:1540 KELLER PKWY STE 108-168
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3686
Practice Address - Country:US
Practice Address - Phone:469-850-3114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health