Provider Demographics
NPI:1003245838
Name:WIREGRASS WOUND CARE CONSULTANTS LLC
Entity Type:Organization
Organization Name:WIREGRASS WOUND CARE CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:FADIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-295-2815
Mailing Address - Street 1:725 N HIGHWAY A1A
Mailing Address - Street 2:SUITE C112-113
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477-4571
Mailing Address - Country:US
Mailing Address - Phone:561-578-8407
Mailing Address - Fax:561-578-8099
Practice Address - Street 1:1908 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3008
Practice Address - Country:US
Practice Address - Phone:251-295-2815
Practice Address - Fax:251-295-2815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty