Provider Demographics
NPI:1922012608
Name:NATIONAL WOUND CARE LLC
Entity Type:Organization
Organization Name:NATIONAL WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-355-2680
Mailing Address - Street 1:3356 BIG PINE TRL STE D
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1405
Mailing Address - Country:US
Mailing Address - Phone:217-355-2680
Mailing Address - Fax:217-355-5538
Practice Address - Street 1:4112B FIELDSTONE RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-8810
Practice Address - Country:US
Practice Address - Phone:217-355-2680
Practice Address - Fax:217-355-5538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28251100Medicaid
IL371386148001OtherPUBLIC AID
1119627OtherPASSPORT
OH2208828Medicaid
IL1029939OtherBLUE CROSS BLUE SHIELD
IN200397280AMedicaid
90001322OtherUNISYS
FLR9560OtherBLUE CROSS BLUE SHIELD
371386148OtherTRICARE
TN4582222Medicaid
1119627OtherPASSPORT
IL371386148001OtherPUBLIC AID