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Organization

WIREGRASS CLINIC LLC

Active
Parent organization
WIREGRASS CLINIC LLC
Organization subpart
Yes

Provider details

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

Contact information

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

Taxonomy

Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary

Other

Enumeration date
10/01/2021
Last updated
10/01/2021
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