Healthcare Provider Details

I. General information

NPI: 1639061757
Provider Name (Legal Business Name): ILLINOIS MOBILE WOUND PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 EVERGREEN LN UNIT A
GLEN CARBON IL
62034-1754
US

IV. Provider business mailing address

220 EVERGREEN LN UNIT A
GLEN CARBON IL
62034-1754
US

V. Phone/Fax

Practice location:
  • Phone: 618-655-0333
  • Fax:
Mailing address:
  • Phone: 618-655-0333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA CLELAND
Title or Position: MANAGER
Credential:
Phone: 618-980-2181