Provider Demographics
NPI:1508566035
Name:UNIVERSAL WOUND MANAGEMENT, INC
Entity Type:Organization
Organization Name:UNIVERSAL WOUND MANAGEMENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:A J
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-226-2332
Mailing Address - Street 1:1550 E WASHINGTON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4624
Mailing Address - Country:US
Mailing Address - Phone:302-200-9686
Mailing Address - Fax:909-370-4405
Practice Address - Street 1:3140 RED HILL AVE STE 150
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3440
Practice Address - Country:US
Practice Address - Phone:302-200-9686
Practice Address - Fax:909-370-4405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-03
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5259844OtherCA SECRETARY OF STATE