Healthcare Provider Details

I. General information

NPI: 1083857049
Provider Name (Legal Business Name): INNOVATIONS WOUND MANAGEMENT, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 WAGNER ST
HOUSTON TX
77007-3719
US

IV. Provider business mailing address

1234 WAGNER ST
HOUSTON TX
77007-3719
US

V. Phone/Fax

Practice location:
  • Phone: 713-868-3301
  • Fax: 713-868-4817
Mailing address:
  • Phone: 713-868-3301
  • Fax: 713-868-4817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE8768
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM1782
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberN6545
License Number StateTX

VIII. Authorized Official

Name: MS. MOIRA HAYES
Title or Position: PRACTICE ADMINISTRATOR
Credential: MHA, RRT, CHT
Phone: 713-301-5707