Provider Demographics
NPI:1528084266
Name:ADVANCED WOUND CARE LLC
Entity type:Organization
Organization Name:ADVANCED WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEISKY
Authorized Official - Suffix:
Authorized Official - Credentials:NP CWC
Authorized Official - Phone:217-698-3505
Mailing Address - Street 1:426 TYRONE DR
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-1069
Mailing Address - Country:US
Mailing Address - Phone:217-698-3505
Mailing Address - Fax:217-698-3502
Practice Address - Street 1:2524 FARRAGUT DR # C
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-8400
Practice Address - Country:US
Practice Address - Phone:217-698-3505
Practice Address - Fax:217-698-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1528084266OtherNPI GROUP
IL05832068OtherBC BS OF IL
IL30-0024900OtherTAX ID
ILDE5770OtherRR MEDICARE GROUP NUMBER
IL05832068OtherBC BS OF IL