MEDICARE: WYNN INNOVATIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1043928948
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYNN INNOVATIONS LLC

Provider Business Mailing Address
First Line	:	1621 SHELTER COVE DR
Second Line	:
City	:	GREENWOOD
State	:	CA
Zip	:	95635-9509
Country	:	US
Telephone Number	:	916-996-6377
Fax Number	:

Provider Business Practice Location Address
First Line	:	1621 SHELTER COVE DR
Second Line	:
City	:	GREENWOOD
State	:	CA
Zip	:	95635-9509
Country	:	US
Telephone Number	:	916-996-6377
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BENJAMIN WYNN
Credential	:
Telephone Number	:	916-996-6377

Provider Enumeration Date	:	11/09/2022
Last Update Date	:	12/19/2022

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Directions to “WYNN INNOVATIONS LLC ” Practice Location

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