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NPI Code Detail

MEDICARE: SPECIALIZED WOUND MANAGEMENT GREAT LAKES, LLC

MEDICARE: SPECIALIZED WOUND MANAGEMENT GREAT LAKES, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1760536387
Entity Type Code : Organization
Provider Name (Legal Business Name) : SPECIALIZED WOUND MANAGEMENT GREAT LAKES, LLC
Provider Business Mailing Address
First Line : 2500 EXECUTIVE DRIVE
Second Line : SUITE 104
City : ST CHARLES
State : MO
Zip : 63303
Country : US
Telephone Number : 636-447-2509
Fax Number : 636-447-3095
Provider Business Practice Location Address
First Line : 5700 W LAYTON AVE
Second Line :
City : GREENFIELD
State : WI
Zip : 53220-4016
Country : US
Telephone Number : 414-281-7201
Fax Number : 414-281-0744
Authorized Official
Title or Position : CFO
Name : MR. STEVEN KELLEY
Credential :
Telephone Number : 636-447-2509
Provider Enumeration Date : 01/22/2007
Last Update Date : 08/22/2020

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Directions to “SPECIALIZED WOUND MANAGEMENT GREAT LAKES, LLC ” Practice Location

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