Provider Demographics
NPI:1720081409
Name:WIREGRASS HOSPICE, LLC
Entity Type:Organization
Organization Name:WIREGRASS HOSPICE, LLC
Other - Org Name:GENTIVA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF LICENSURE
Authorized Official - Prefix:MS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:COMBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-2876
Mailing Address - Street 1:PO BOX 4060
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-4060
Mailing Address - Country:US
Mailing Address - Phone:704-664-2876
Mailing Address - Fax:704-664-1306
Practice Address - Street 1:750 E SPRING ST STE B1
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4528
Practice Address - Country:US
Practice Address - Phone:931-528-5133
Practice Address - Fax:931-372-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ019266Medicaid
0133059OtherBLUECROSSBLUESHIELD
292638OtherFEDERAL BLACK LUNG PROG
TN0441520Medicaid
TN441520Medicaid
292638OtherFEDERAL BLACK LUNG PROG