Healthcare Provider Details

I. General information

NPI: 1538043211
Provider Name (Legal Business Name): MODERM WOUND CARE SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2263 FINCH CIR
SAN JACINTO CA
92582-6964
US

IV. Provider business mailing address

2263 FINCH CIR
SAN JACINTO CA
92582-6964
US

V. Phone/Fax

Practice location:
  • Phone: 888-211-1498
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TAMARA PIPPIN
Title or Position: OWNER
Credential:
Phone: 888-211-1498