1851063432 NPI number — WIREGRASS CLINIC LLC

Table of content: (NPI 1851063432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851063432 NPI number — WIREGRASS CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WIREGRASS CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851063432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 689022
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37068-9022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-465-7230
Provider Business Mailing Address Fax Number:
615-628-6877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 W MAIN ST STE 405
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36305-1086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-944-7073
Provider Business Practice Location Address Fax Number:
334-944-7058
Provider Enumeration Date:
10/01/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SR DIR PROV ENROLLMENT & ONBOARDING
Authorized Official Telephone Number:
615-465-3334

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)