MEDICARE: INNOVATIONS WOUND MANAGEMENT, PA

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	363LG0600X	Gerontology Nurse Practitioner	601127	TX

General Provider Information

NPI Number	:	1225354475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIONS WOUND MANAGEMENT, PA

Provider Business Mailing Address
First Line	:	1234 WAGNER ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-3719
Country	:	US
Telephone Number	:	713-301-5707
Fax Number	:	713-295-2863

Provider Business Practice Location Address
First Line	:	1234 WAGNER ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-3719
Country	:	US
Telephone Number	:	713-301-5707
Fax Number	:	713-295-2863

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MS. MOIRA HAYES
Credential	:	MHA, RRT, CHT
Telephone Number	:	713-301-5707

Provider Enumeration Date	:	04/13/2010
Last Update Date	:	04/13/2010

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