Healthcare Provider Details

I. General information

NPI: 1740358837
Provider Name (Legal Business Name): PROFESSIONAL RESOURCE MANAGMENT OF WIREGRASS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 ANDREWS AVE
OZARK AL
36360-3726
US

IV. Provider business mailing address

2812 HARTFORD HWY STE 1
DOTHAN AL
36305-4927
US

V. Phone/Fax

Practice location:
  • Phone: 334-774-1555
  • Fax:
Mailing address:
  • Phone: 334-712-1170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: NANCY A GILLEY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 334-712-1170