Provider Demographics
NPI:1568638534
Name:WIREGRASS MENTAL HEALTH BOARD INC
Entity Type:Organization
Organization Name:WIREGRASS MENTAL HEALTH BOARD INC
Other - Org Name:SPECTRACARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-712-2720
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:2694 SOUTH PARK AVE.
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1245
Mailing Address - Country:US
Mailing Address - Phone:334-712-2720
Mailing Address - Fax:334-712-2727
Practice Address - Street 1:134 PREVATT RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-5427
Practice Address - Country:US
Practice Address - Phone:334-794-0731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000008817OtherMEDICARE
AL590000010Medicaid
AL331600587Medicaid
FL059726100Medicaid
AL20427OtherMEDICARESECONDARY
AL331000069Medicaid
AL330034010Medicaid
AL331000067Medicaid
AL331000467Medicaid
AL51003550OtherCOMMERCIAL INS.
AL33000067Medicaid
AL33034010Medicaid
AL591500003Medicaid
AL14609OtherMEDICARE SECONDARY
AL330000010Medicaid
AL51043902OtherBLUE CROSS BLUE SHIELD
AL591600003Medicaid
AL14635OtherMEDICARE SECONDARY
AL331600592Medicaid