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General NPI Number Information
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NPI Number | 1205390457
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Entity Type | Organization
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Legal Business Name | INTEGRATED WOUND CARE MINNESOTA PLLC
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Dates
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Enumeration Date | 01/22/2019
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Last Update Date | 01/12/2026
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Provider Practice Location Address
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Address Line | 433 COUNTY ROAD 30 SE
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City | DELANO
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State | MN
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Zip | 55328-9000
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Country | US
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Telephone | 718-705-6010
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Fax |
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Provider Business Mailing Address
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Address Line | 492C CEDAR LN STE 514
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City | TEANECK
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State | NJ
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Zip | 07666-1713
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Country | US
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Telephone | 718-705-6010
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DIANE LUSAS
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Credential | MD
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Telephone | 212-734-6621
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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