1568638534 NPI number — WIREGRASS MENTAL HEALTH BOARD INC

Table of content: (NPI 1568638534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568638534 NPI number — WIREGRASS MENTAL HEALTH BOARD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WIREGRASS MENTAL HEALTH BOARD INC
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:
SPECTRACARE
Provider Other Organization Name Type Code:
3
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:
1568638534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1245
Provider Second Line Business Mailing Address:
2694 SOUTH PARK AVE.
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36302-1245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-712-2720
Provider Business Mailing Address Fax Number:
334-712-2727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
134 PREVATT RD
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:
36301-5427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-794-0731
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KIRKLAND
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
334-712-2720

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000008817 . This is a "MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 590000010 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 331600587 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 059726100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20427 . This is a "MEDICARESECONDARY" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 331000069 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 330034010 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 331000067 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 331000467 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51003550 . This is a "COMMERCIAL INS." identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 33000067 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33034010 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 591500003 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14609 . This is a "MEDICARE SECONDARY" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 330000010 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51043902 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 591600003 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14635 . This is a "MEDICARE SECONDARY" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 331600592 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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