Provider Demographics
NPI:1962396424
Name:SOUTHWEST FLORIDA ADVANCED WOUND CARE, LLC
Entity type:Organization
Organization Name:SOUTHWEST FLORIDA ADVANCED WOUND CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAILBREATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-212-4142
Mailing Address - Street 1:1907 MENDOCINO LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-7409
Mailing Address - Country:US
Mailing Address - Phone:386-212-4142
Mailing Address - Fax:
Practice Address - Street 1:1813 PALACO GRANDE PKWY
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-4445
Practice Address - Country:US
Practice Address - Phone:386-212-4142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty