Provider Demographics
NPI:1740358837
Name:PROFESSIONAL RESOURCE MANAGMENT OF WIREGRASS, LLC
Entity type:Organization
Organization Name:PROFESSIONAL RESOURCE MANAGMENT OF WIREGRASS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-712-1170
Mailing Address - Street 1:2812 HARTFORD HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4927
Mailing Address - Country:US
Mailing Address - Phone:334-712-1170
Mailing Address - Fax:
Practice Address - Street 1:1970 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3726
Practice Address - Country:US
Practice Address - Phone:334-774-1555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALK365OtherMEDICARE GROUP
AL529923390Medicaid