=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427932938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKINTEGRITY WOUND CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2025
-----------------------------------------------------
Last Update Date | 08/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17919 MACKESON CT
-----------------------------------------------------
City | CARSON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90746-1629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-644-8302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17919 MACKESON CT
-----------------------------------------------------
City | CARSON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90746-1629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-644-8302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | HENRY PEKUN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-877-5368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------