MEDICARE: SOUTHWEST FLORIDA ADVANCED WOUND CARE, 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
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1962396424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST FLORIDA ADVANCED WOUND CARE, LLC

Provider Business Mailing Address
First Line	:	1907 MENDOCINO LN
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-7409
Country	:	US
Telephone Number	:	386-212-4142
Fax Number	:

Provider Business Practice Location Address
First Line	:	1813 PALACO GRANDE PKWY
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33904-4445
Country	:	US
Telephone Number	:	386-212-4142
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JESSICA GAILBREATH
Credential	:
Telephone Number	:	386-212-4142

Provider Enumeration Date	:	06/06/2025
Last Update Date	:	06/06/2025

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