=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033801568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE WOUND CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2023
-----------------------------------------------------
Last Update Date | 05/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67 MASONIC AVE STE 2400
-----------------------------------------------------
City | WALLINGFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06492-3099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-408-2462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 AUTUMN CT
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-408-2462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. ADRIAN WYLLIE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 203-408-2462
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------