Provider Demographics
NPI:1952873283
Name:WIREGRASS PODIATRY LLC
Entity Type:Organization
Organization Name:WIREGRASS PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:334-494-8200
Mailing Address - Street 1:1008 BOLL WEEVIL CIR STE B
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-3400
Mailing Address - Country:US
Mailing Address - Phone:334-494-8200
Mailing Address - Fax:334-460-1984
Practice Address - Street 1:1008 BOLL WEEVIL CIR STE B
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-3400
Practice Address - Country:US
Practice Address - Phone:334-494-8200
Practice Address - Fax:334-460-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-27
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty