Provider Demographics
NPI:1013117167
Name:WIREGRASS WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:WIREGRASS WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KENTON
Authorized Official - Last Name:STRUNK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-215-0627
Mailing Address - Street 1:PO BOX 8308
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36304-0308
Mailing Address - Country:US
Mailing Address - Phone:334-673-8869
Mailing Address - Fax:334-673-8851
Practice Address - Street 1:201 REGENCY CT
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1179
Practice Address - Country:US
Practice Address - Phone:334-673-8869
Practice Address - Fax:334-673-8851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL229432Medicaid
FL914438200Medicaid
FL1080690OtherBEACON
11498415OtherCAQH
AL410459675OtherTRICARE
FL50198OtherFLORIDA BLUE
AL601701400OtherDOL
AL009966175Medicaid
FL010838800Medicaid
AL188102Medicaid
AL774089000OtherMAGELLAN
AL0348462OtherCIGNA
1104332527OtherNPI
GA407098142CMedicaid
AL529920780Medicaid
FLQ6YNLOtherFLORIDA BCBS
AL51521565OtherBCBS
$$$$$$$$$OtherSSN
1013117167OtherNPI
1811983596OtherNPI
AL19C1ROtherNEW DIRECTIONS
AL523314OtherVALUE OPTIONS