Basic Information
| Provider Information | |||||||||
| NPI: | 1477946820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED WOUND CARE OF NORTH FLORIDA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 PRINCE PHILLIP DR | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320921746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133801492 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13500 SUTTON PARK DR S | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322245251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044933390 | ||||||||
| FaxNumber: | 9044933395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2015 | ||||||||
| LastUpdateDate: | 03/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | LAGOUTARIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | DEMETRIOS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8133801492 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO3240 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | PO3240 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213EP1101X | PO3240 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
No ID Information.