Organization
ADVANCED WOUND CARE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ROXANNE LEISKY NP CWC (OWNER)
(217) 698-3505
Entity
Organization
Contact information
Practice address
2524 FARRAGUT DR # C, SPRINGFIELD, IL 62704-8400
(217) 698-3505
(217) 698-3502
Mailing address
426 TYRONE DR, FORSYTH, IL 62535-1069
(217) 698-3505
(217) 698-3502
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
05832068
BC BS OF IL
IL
01
—
1528084266
NPI GROUP
IL
01
—
30-0024900
TAX ID
IL
01
—
DE5770
RR MEDICARE GROUP NUMBER
IL
Enumeration date
07/14/2006
Last updated
01/16/2008
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