Provider Demographics
NPI:1760536387
Name:SPECIALIZED WOUND MANAGEMENT GREAT LAKES, LLC
Entity Type:Organization
Organization Name:SPECIALIZED WOUND MANAGEMENT GREAT LAKES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-447-2509
Mailing Address - Street 1:2500 EXECUTIVE DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ST CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303
Mailing Address - Country:US
Mailing Address - Phone:636-447-2509
Mailing Address - Fax:636-447-3095
Practice Address - Street 1:5700 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4016
Practice Address - Country:US
Practice Address - Phone:414-281-7201
Practice Address - Fax:414-281-0744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility