Basic Information
| Provider Information | |||||||||
| NPI: | 1912253865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | L BILLY WOUNDCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9375 E VISTA DR | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630503218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6367972611 | ||||||||
| FaxNumber: | 6367972611 | ||||||||
| Practice Location | |||||||||
| Address1: | 3933 S BROADWAY | ||||||||
| Address2: | LIMB PRESERVATION CENTER | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631184601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148657000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2012 | ||||||||
| LastUpdateDate: | 07/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | BILLY | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED AGENT | ||||||||
| AuthorizedOfficialTelephone: | 6367972611 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 30514 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200026920 | 05 | MO | MEDICAID |