Provider Demographics
NPI:1396313110
Name:PI: PREVENTION AND INTERVENTION WOUND CARE AND DERMATOLOGICAL SERVICES
Entity type:Organization
Organization Name:PI: PREVENTION AND INTERVENTION WOUND CARE AND DERMATOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP-C
Authorized Official - Phone:813-340-5499
Mailing Address - Street 1:10420 MCKINLEY DR APT 9312
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-6448
Mailing Address - Country:US
Mailing Address - Phone:813-340-5499
Mailing Address - Fax:
Practice Address - Street 1:10420 MCKINLEY DR APT 9312
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6448
Practice Address - Country:US
Practice Address - Phone:813-340-5499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care