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Tanner Primary Care of Wedowee, Inc.

Details

Name: Tanner Primary Care of Wedowee, Inc.
Jurisdiction: Alabama
Legal type: Foreign Non-Profit Corporation
Status: Exists
Date of registration: 19 Mar 2012 (13 years ago) (Companies founded in March 2012)
Entity Number: 000-276-619
Register Number: 000276619
ZIP code: 36278 (Companies in Randolph, 36278)
County: Randolph
Place of Formation: Georgia
Principal Mailing Address: 705 DIXIE STREETCARROLLTON, GA 30117
Principal Address: 108 WOODLAND AVENUEWEDOWEE, AL 36278

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1396002515 2012-04-12 2024-02-29 100 GREENWAY BLVD FL 2, CARROLLTON, GA, 301174338, US 1030 MAIN ST S, WEDOWEE, AL, 362787440, US

Contacts

Phone +1 770-838-8710
Fax 7708125735
Phone +1 256-357-2188
Fax 2563572023

Authorized person

Name CLINT HOFFMAN
Role SR VP
Phone 7708128845

Taxonomy

Taxonomy Code 207Q00000X - Family Medicine Physician
Is Primary No
Taxonomy Code 261QR1300X - Rural Health Clinic/Center
Is Primary Yes

Other Provider Identifiers

Issuer MEDICAID
Number 139022
State AL
Issuer RHC CERTIFICATION NUMBER
Number 01-8904
State AL
Issuer MEDICAID
Number 155218
State AL

Agent

Name Role
ARMBRESTER, JILL Agent

Date of last update: 02 Aug 2024

Sources: Alabama Secretary of State