# WIREGRASS CLINIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** WIREGRASS CLINIC LLC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1851063432
- **Legal business name:** WIREGRASS CLINIC LLC
- **Authorized official:** JENNIFER L JACKSON (SR DIR PROV ENROLLMENT & ONBOARDING)
- **Authorized official phone:** (615) 465-3334

## Contact information

- **Practice address:** 4300 W MAIN ST STE 405, DOTHAN, AL 36305-1086
- **Practice address phone:** (334) 944-7073
- **Practice address fax:** (334) 944-7058
- **Mailing address:** PO BOX 689022, FRANKLIN, TN 37068-9022
- **Mailing address phone:** (615) 465-7230
- **Mailing address fax:** (615) 628-6877

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 10/01/2021
- **Last updated:** 10/01/2021