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General NPI Number Information
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NPI Number | 1720964349
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Entity Type | Organization
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Legal Business Name | LA IDEAL WOUND INC
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Dates
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Enumeration Date | 08/12/2025
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Last Update Date | 08/12/2025
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Provider Practice Location Address
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Address Line | 201 VICTORY BLVD SUITE 287
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City | MONROE
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State | TX
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Zip | 71203
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Country | US
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Telephone | 877-969-6863
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Fax |
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Provider Business Mailing Address
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Address Line | 1810 8TH AVE STE A101
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City | FORT WORTH
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State | TX
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Zip | 76110-1352
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Country | US
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Telephone | 877-969-6863
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Fax |
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | TRACI PIERSANTI
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Credential |
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Telephone | 877-969-6863
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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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 | 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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