Healthcare Provider Details

I. General information

NPI: 1023455953
Provider Name (Legal Business Name): EASTERN SHORE DEVELOPMENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2013
Last Update Date: 06/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26420 KENSINGTON PL STE A
DAPHNE AL
36526-5123
US

IV. Provider business mailing address

26420 KENSINGTON PL STE A
DAPHNE AL
36526-5123
US

V. Phone/Fax

Practice location:
  • Phone: 251-625-0400
  • Fax:
Mailing address:
  • Phone: 251-625-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00008950
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1076812
License Number StateAL

VIII. Authorized Official

Name: DR. WARNER MERRILL WIGGINS
Title or Position: OFFICAL
Credential: MD
Phone: 251-402-5589