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General NPI Number Information
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NPI Number | 1134928419
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Entity Type | Organization
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Legal Business Name | PROACTIVE WOUND CARE ID INC.
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Dates
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Enumeration Date | 03/10/2025
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Last Update Date | 03/10/2025
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Provider Practice Location Address
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Address Line | 2270 HIGHWAY 89
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City | FISH HAVEN
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State | ID
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Zip | 83287-5139
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Country | US
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Telephone | 801-815-6862
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 607
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City | CENTERVILLE
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State | UT
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Zip | 84014-0607
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Country | US
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Telephone | 801-815-6862
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | HAYLEY WILLIAMS
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Credential |
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Telephone | 801-815-6862
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number |
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License Number State |
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