Provider Demographics
NPI:1538741053
Name:INNOVATIVE WOUND HEALING & DERMATOLOGY
Entity type:Organization
Organization Name:INNOVATIVE WOUND HEALING & DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-425-2805
Mailing Address - Street 1:21137 SR 410 E STE I
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-8775
Mailing Address - Country:US
Mailing Address - Phone:800-425-2805
Mailing Address - Fax:855-673-1403
Practice Address - Street 1:21137 SR 410 E STE I
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8775
Practice Address - Country:US
Practice Address - Phone:800-425-2805
Practice Address - Fax:855-673-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-23
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty