Provider Demographics
NPI:1326883174
Name:LAS VEGAS WOUND CARE CLINIC LLC
Entity type:Organization
Organization Name:LAS VEGAS WOUND CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:EDSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:470-363-3311
Mailing Address - Street 1:2855 S BRONCO ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2855 S BRONCO ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5207
Practice Address - Country:US
Practice Address - Phone:470-363-3311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care