Provider Demographics
NPI:1467030726
Name:WIREGRASS REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:WIREGRASS REHABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-792-0022
Mailing Address - Street 1:795 ROSS CLARK CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-5306
Mailing Address - Country:US
Mailing Address - Phone:334-792-0022
Mailing Address - Fax:
Practice Address - Street 1:795 ROSS CLARK CIR STE 1
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-5306
Practice Address - Country:US
Practice Address - Phone:334-792-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health