1356782809 NPI number — INNOVATIVE WOUND CARE ASSOCIATES INC

Table of content: (NPI 1356782809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356782809 NPI number — INNOVATIVE WOUND CARE ASSOCIATES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE WOUND CARE ASSOCIATES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356782809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N KEEL RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMITAGE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16148-3440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-347-0591
Provider Business Mailing Address Fax Number:
724-347-4901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
790 BOARDMAN CANFIELD RD STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-4344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-758-4862
Provider Business Practice Location Address Fax Number:
330-758-4886
Provider Enumeration Date:
07/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BALKO
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
724-347-0591

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  2227258 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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