Healthcare Provider Details

I. General information

NPI: 1215593009
Provider Name (Legal Business Name): IHC-WOUND CARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6308 8TH AVE
KENOSHA WI
53143-5031
US

IV. Provider business mailing address

PO BOX 99035
LAS VEGAS NV
89193-9035
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6718
  • Fax:
Mailing address:
  • Phone: 414-290-6718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN VAUGHN
Title or Position: OFFICER
Credential:
Phone: 973-251-1132