MEDICARE: WIDE RANGE OF RESOURCES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	CSW00658	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	GRP7368	OTHER	GA	MEDICARE GROUP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043459878
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIDE RANGE OF RESOURCES, INC

Provider Business Mailing Address
First Line	:	1776 N JEFFERSON ST NE
Second Line	:	SUITE B
City	:	MILLEDGEVILLE
State	:	GA
Zip	:	31061-2229
Country	:	US
Telephone Number	:	478-451-3112
Fax Number	:	478-451-0626

Provider Business Practice Location Address
First Line	:	1776 N JEFFERSON ST NE
Second Line	:	SUITE B
City	:	MILLEDGEVILLE
State	:	GA
Zip	:	31061-2229
Country	:	US
Telephone Number	:	478-451-3112
Fax Number	:	478-451-0626

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MRS. FREZALIA L. OLIVER
Credential	:	LCSW
Telephone Number	:	478-451-3112

Provider Enumeration Date	:	02/18/2009
Last Update Date	:	02/18/2009

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