| Name: | Wiregrass Wellness Center LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 11 Jun 2004 (20 years ago) |
| Entity Number: | 000-452-265 |
| Register Number: | 000452265 |
| County: | Houston |
| Place of Formation: | Houston County |
| Principal Address: | DOTHAN, AL |
| Registered Office Street Address: | 2431 WEST MAIN ST STE 306DOTHAN, AL 36301 |
| Registered Office Street Address ZIP Code: | 36301 |
Activities
PSYCHIATRIC MEDICAL PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 1013117167 | 2007-07-18 | 2020-05-21 | PO BOX 8308, DOTHAN, AL, 363040308, US | 201 REGENCY CT, DOTHAN, AL, 363051179, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 334-673-8869 |
| Fax | 3346738851 |
Authorized person
| Name | MR. DAVID KENTON STRUNK |
| Role | CFO |
| Phone | 4232150627 |
Taxonomy
| Taxonomy Code | 2084A0401X - Addiction Medicine (Psychiatry & Neurology) Physician |
| Is Primary | No |
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| Is Primary | Yes |
| Taxonomy Code | 2084P0805X - Geriatric Psychiatry Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 229432 |
| State | AL |
| Issuer | MEDICAID |
| Number | 914438200 |
| State | FL |
| Issuer | BEACON |
| Number | 1080690 |
| State | FL |
| Issuer | CAQH |
| Number | 11498415 |
| Issuer | TRICARE |
| Number | 410459675 |
| State | AL |
| Issuer | FLORIDA BLUE |
| Number | 50198 |
| State | FL |
| Issuer | DOL |
| Number | 601701400 |
| State | AL |
| Issuer | MEDICAID |
| Number | 009966175 |
| State | AL |
| Issuer | MEDICAID |
| Number | 010838800 |
| State | FL |
| Issuer | MEDICAID |
| Number | 188102 |
| State | AL |
| Issuer | MAGELLAN |
| Number | 774089000 |
| State | AL |
| Issuer | CIGNA |
| Number | 0348462 |
| State | AL |
| Issuer | NPI |
| Number | 1104332527 |
| Issuer | MEDICAID |
| Number | 407098142C |
| State | GA |
| Issuer | MEDICAID |
| Number | 529920780 |
| State | AL |
| Issuer | FLORIDA BCBS |
| Number | Q6YNL |
| State | FL |
| Issuer | BCBS |
| Number | 51521565 |
| State | AL |
| Issuer | SSN |
| Number | $$$$$$$$$ |
| Issuer | NPI |
| Number | 1013117167 |
| Issuer | NPI |
| Number | 1811983596 |
| Issuer | NEW DIRECTIONS |
| Number | 19C1R |
| State | AL |
| Issuer | VALUE OPTIONS |
| Number | 523314 |
| State | AL |
| Name | Role |
|---|---|
| STRUNK, JOHN CHRIS | Agent |
| Name | Role |
|---|---|
| STRUNK, JOHN CHRIS | Member |
| STRUNK, DAVID KENTON | Member |
| STRUNK, BARBARA COFFEY | Member |
Date of last update: 13 Aug 2024
Sources: Alabama Secretary of State
