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:2025-04-04
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
AL0348462OtherCIGNA
AL601701400OtherDOL
AL774089000OtherMAGELLAN
1013117167OtherNPI
AL529920780Medicaid
FL1080690OtherBEACON
1104332527OtherNPI
11498415OtherCAQH
1811983596OtherNPI
AL229432Medicaid
AL188102Medicaid
AL009966175Medicaid
AL51521565OtherBCBS
FL010838800Medicaid
AL523314OtherVALUE OPTIONS
FL914438200Medicaid
AL19C1ROtherNEW DIRECTIONS
GA407098142CMedicaid
FL50198OtherFLORIDA BLUE
AL410459675OtherTRICARE
FLQ6YNLOtherFLORIDA BCBS
AL523314OtherVALUE OPTIONS