Provider Demographics
NPI:1043366677
Name:ADVANCED WOUND CARE, LLC
Entity Type:Organization
Organization Name:ADVANCED WOUND CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-362-8630
Mailing Address - Street 1:2363 W JEFFERSON AVE
Mailing Address - Street 2:SUITE 219
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2705
Mailing Address - Country:US
Mailing Address - Phone:734-362-8630
Mailing Address - Fax:
Practice Address - Street 1:2363 W JEFFERSON AVE
Practice Address - Street 2:SUITE 219
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2705
Practice Address - Country:US
Practice Address - Phone:734-362-8630
Practice Address - Fax:734-362-8631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI874963400Medicaid
MI540H27190OtherBCBS OF MI
MI540H27190OtherBCBS OF MI