Provider Demographics
NPI:1003244138
Name:INNOVATION WOUND CARE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:INNOVATION WOUND CARE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:MAKABALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-569-2828
Mailing Address - Street 1:20 E SUNRISE HWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1260
Mailing Address - Country:US
Mailing Address - Phone:516-569-2828
Mailing Address - Fax:516-295-4145
Practice Address - Street 1:20 E SUNRISE HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1260
Practice Address - Country:US
Practice Address - Phone:516-569-2828
Practice Address - Fax:516-295-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115251174400000X
NY006327213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty