Provider Demographics
NPI:1407681745
Name:WOUND ICONS INC
Entity type:Organization
Organization Name:WOUND ICONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:
Authorized Official - Last Name:IVOKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-824-5099
Mailing Address - Street 1:9087 ARROW RTE STE 246
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4488
Mailing Address - Country:US
Mailing Address - Phone:562-824-5099
Mailing Address - Fax:909-784-0617
Practice Address - Street 1:9087 ARROW RTE STE 246
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4488
Practice Address - Country:US
Practice Address - Phone:562-824-5099
Practice Address - Fax:909-784-0617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care