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General NPI Number Information
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NPI Number | 1528084266
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Entity Type | Organization
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Legal Business Name | ADVANCED WOUND CARE LLC
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Dates
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Enumeration Date | 07/14/2006
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Last Update Date | 01/16/2008
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Provider Practice Location Address
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Address Line | 2524 FARRAGUT DR # C
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City | SPRINGFIELD
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State | IL
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Zip | 62704-8400
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Country | US
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Telephone | 217-698-3505
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Fax | 217-698-3502
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Provider Business Mailing Address
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Address Line | 426 TYRONE DR
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City | FORSYTH
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State | IL
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Zip | 62535-1069
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Country | US
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Telephone | 217-698-3505
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Fax | 217-698-3502
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Authorized Official
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Title or Position | OWNER
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Name | MRS. ROXANNE LEISKY
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Credential | NP CWC
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Telephone | 217-698-3505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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