Provider Demographics
NPI:1669296364
Name:WOUND CARE OF WISCONSIN LLC
Entity type:Organization
Organization Name:WOUND CARE OF WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOHOWIAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-324-9899
Mailing Address - Street 1:160 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-2276
Mailing Address - Country:US
Mailing Address - Phone:920-324-9899
Mailing Address - Fax:
Practice Address - Street 1:160 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-2276
Practice Address - Country:US
Practice Address - Phone:920-324-9899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-11
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty