Healthcare Provider Details

I. General information

NPI: 1134928419
Provider Name (Legal Business Name): PROACTIVE WOUND CARE ID INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 HIGHWAY 89
FISH HAVEN ID
83287-5139
US

IV. Provider business mailing address

PO BOX 607
CENTERVILLE UT
84014-0607
US

V. Phone/Fax

Practice location:
  • Phone: 801-815-6862
  • Fax:
Mailing address:
  • Phone: 801-815-6862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: HAYLEY WILLIAMS
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-815-6862