Healthcare Provider Details

I. General information

NPI: 1003244138
Provider Name (Legal Business Name): INNOVATION WOUND CARE ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 E SUNRISE HWY SUITE 301
VALLEY STREAM NY
11581-1260
US

IV. Provider business mailing address

20 E SUNRISE HWY SUITE 301
VALLEY STREAM NY
11581-1260
US

V. Phone/Fax

Practice location:
  • Phone: 516-569-2828
  • Fax: 516-295-4145
Mailing address:
  • Phone: 516-569-2828
  • Fax: 516-295-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number115251
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number006327
License Number StateNY

VIII. Authorized Official

Name: DR. GILBERT G. MAKABALI
Title or Position: PRESIDENT
Credential: MD
Phone: 516-569-2828