Provider Demographics
NPI:1992101471
Name:SOUTHEAST WOUNDCARE EXPERTS LLC
Entity type:Organization
Organization Name:SOUTHEAST WOUNDCARE EXPERTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LUCKY
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:305-238-3990
Mailing Address - Street 1:13520 SW 152ND ST
Mailing Address - Street 2:NUMBER 771834
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-0194
Mailing Address - Country:US
Mailing Address - Phone:305-238-3990
Mailing Address - Fax:305-254-6331
Practice Address - Street 1:13520 SW 152ND ST
Practice Address - Street 2:NUMBER 771834
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-0101
Practice Address - Country:US
Practice Address - Phone:305-238-3990
Practice Address - Fax:305-254-6331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29049174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038136500Medicaid
FL038136500Medicaid
FLK5918CMedicare PIN