Provider Demographics
NPI:1770519324
Name:WIREGRASS HOSPICE, LLC
Entity type:Organization
Organization Name:WIREGRASS HOSPICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:2431 W MAIN ST STE 1102
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1250
Practice Address - Country:US
Practice Address - Phone:334-792-1100
Practice Address - Fax:334-671-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
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
ALPIC 1014EMedicaid
ALPIC 1018EMedicaid
ALPIC 1023EMedicaid
ALPIC 1024EMedicaid
ALPIC 1025EMedicaid
ALPIC 1027EMedicaid
ALPIC 1026EMedicaid
ALPIC 1017EMedicaid
ALPIC 1522EMedicaid
011522Medicare Oscar/Certification
ALPIC 1016EMedicaid
ALPIC 1018EMedicaid
ALPIC 1019EMedicaid
ALPIC 1024EMedicaid
ALPIC 1020EMedicaid
ALPIC 1025EMedicaid
ALPIC 1027EMedicaid
GA00641154DMedicaid
ALPIC 1023EMedicaid
ALPIC 1037EMedicaid