Provider Demographics
NPI:1013076025
Name:WILDER HEALTH CARE CENTER, LLC
Entity Type:Organization
Organization Name:WILDER HEALTH CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:256-825-7881
Mailing Address - Street 1:345 E LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:DADEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36853-1415
Mailing Address - Country:US
Mailing Address - Phone:256-825-7881
Mailing Address - Fax:256-825-7772
Practice Address - Street 1:345 E LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-1415
Practice Address - Country:US
Practice Address - Phone:256-825-7881
Practice Address - Fax:256-825-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12687314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4756800SMedicaid
AL4756800SMedicaid