Provider Demographics
NPI:1851110837
Name:INNOVATIVE WOUND MANAGEMENT, LLC
Entity type:Organization
Organization Name:INNOVATIVE WOUND MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANALILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-703-1668
Mailing Address - Street 1:3663 E SUNSET RD STE 503
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3299
Mailing Address - Country:US
Mailing Address - Phone:702-703-1668
Mailing Address - Fax:
Practice Address - Street 1:3663 E SUNSET RD STE 503
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3299
Practice Address - Country:US
Practice Address - Phone:702-703-1668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-07
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty