1922012608 NPI number — NATIONAL WOUND CARE LLC

Table of content: (NPI 1922012608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922012608 NPI number — NATIONAL WOUND CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATIONAL WOUND CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922012608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3356 BIG PINE TRL STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61822-1405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-355-2680
Provider Business Mailing Address Fax Number:
217-355-5538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4112B FIELDSTONE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61822-8810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-355-2680
Provider Business Practice Location Address Fax Number:
217-355-5538
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRINCE
Authorized Official First Name:
JOHNNY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
217-355-2680

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 28251100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 371386148001 . This is a "PUBLIC AID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1119627 . This is a "PASSPORT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2208828 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1029939 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200397280A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90001322 . This is a "UNISYS" identifier . This identifiers is of the category "OTHER".
  • Identifier: R9560 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 371386148 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4582222 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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