Provider Demographics
NPI:1902844400
Name:WOUNDCARE AT HOME
Entity Type:Organization
Organization Name:WOUNDCARE AT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:847-337-1396
Mailing Address - Street 1:514 TEELA LN
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1230
Mailing Address - Country:US
Mailing Address - Phone:847-337-1396
Mailing Address - Fax:888-845-9162
Practice Address - Street 1:514 TEELA LN
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1230
Practice Address - Country:US
Practice Address - Phone:847-337-1396
Practice Address - Fax:888-845-9162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060008633363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL332520251001Medicaid
IL332520251001Medicaid
IL26188Medicare ID - Type Unspecified
IL6027270001Medicare NSC