Provider Demographics
NPI:1205390457
Name:INTEGRATED WOUND CARE MINNESOTA PLLC
Entity Type:Organization
Organization Name:INTEGRATED WOUND CARE MINNESOTA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-705-6010
Mailing Address - Street 1:492C CEDAR LN STE 514
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-1713
Mailing Address - Country:US
Mailing Address - Phone:718-705-6010
Mailing Address - Fax:
Practice Address - Street 1:433 COUNTY ROAD 30 SE
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55328-9000
Practice Address - Country:US
Practice Address - Phone:718-705-6010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty