| 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) |
| Entity Number: | 000-276-619 |
| Register Number: | 000276619 |
| County: | Randolph |
| Place of Formation: | Georgia |
| Principal Mailing Address: | 705 DIXIE STREETCARROLLTON, GA 30117 |
| Principal Address: | 108 WOODLAND AVENUEWEDOWEE, AL 36278 |
| Principal Address ZIP Code: | 36278 |
| 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 | |||||||||||||||||||||||||||||||||||||||||
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| 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 |
| Name | Role |
|---|---|
| ARMBRESTER, JILL | Agent |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
