Healthcare Provider Details

I. General information

NPI: 1629935044
Provider Name (Legal Business Name): ADVANCED WOUND THERAPY-MO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W NORTON RD
SPRINGFIELD MO
65803-5303
US

IV. Provider business mailing address

2488 E 81ST ST STE 2000
TULSA OK
74137-4224
US

V. Phone/Fax

Practice location:
  • Phone: 918-592-9020
  • Fax: 918-443-3221
Mailing address:
  • Phone: 918-592-9020
  • Fax: 918-443-3221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT DICKMAN
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 918-592-9020