Healthcare Provider Details

I. General information

NPI: 1013117167
Provider Name (Legal Business Name): WIREGRASS WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 REGENCY CT
DOTHAN AL
36305-1179
US

IV. Provider business mailing address

PO BOX 8308
DOTHAN AL
36304-0308
US

V. Phone/Fax

Practice location:
  • Phone: 334-673-8869
  • Fax: 334-673-8851
Mailing address:
  • Phone: 334-673-8869
  • Fax: 334-673-8851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID KENTON STRUNK
Title or Position: CFO
Credential:
Phone: 423-215-0627