=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699071076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED WOUND CARE CENTERS OF SACRAMENTO, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2011
-----------------------------------------------------
Last Update Date | 02/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3941 J ST #370
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-577-5816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3941 J ST #370
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-577-5816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY / TREASURER
-----------------------------------------------------
Name | MR. PAUL W. MCFALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-577-5816
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------