Provider Demographics
NPI:1043928948
Name:WYNN INNOVATIONS LLC
Entity Type:Organization
Organization Name:WYNN INNOVATIONS LLC
Other - Org Name:WYNN HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-996-6377
Mailing Address - Street 1:1621 SHELTER COVE DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:95635-9509
Mailing Address - Country:US
Mailing Address - Phone:916-996-6377
Mailing Address - Fax:
Practice Address - Street 1:1621 SHELTER COVE DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:CA
Practice Address - Zip Code:95635-9509
Practice Address - Country:US
Practice Address - Phone:916-996-6377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-09
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty