Healthcare Provider Details

I. General information

NPI: 1063882116
Provider Name (Legal Business Name): MOBILE WOUND CARE CONSULTANT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3241 JUSTAMERE RD
WOODRIDGE IL
60517-3759
US

IV. Provider business mailing address

3241 JUSTAMERE RD
WOODRIDGE IL
60517-3759
US

V. Phone/Fax

Practice location:
  • Phone: 630-544-8517
  • Fax:
Mailing address:
  • Phone: 630-544-8517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number041.280969
License Number StateIL

VIII. Authorized Official

Name: MRS. BONNAFE BATICADOS
Title or Position: OWNER
Credential: BSN, RN, WCC
Phone: 630-544-8517