Healthcare Provider Details

I. General information

NPI: 1356782809
Provider Name (Legal Business Name): INNOVATIVE WOUND CARE ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 BOARDMAN CANFIELD RD STE 3
BOARDMAN OH
44512-4344
US

IV. Provider business mailing address

100 N KEEL RIDGE RD
HERMITAGE PA
16148-3440
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-4862
  • Fax: 330-758-4886
Mailing address:
  • Phone: 724-347-0591
  • Fax: 724-347-4901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2227258
License Number StateOH

VIII. Authorized Official

Name: JOHN P BALKO
Title or Position: PRESIDENT
Credential:
Phone: 724-347-0591