Healthcare Provider Details

I. General information

NPI: 1124548623
Provider Name (Legal Business Name): SYDNEY MAURICE WIGGS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 06/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 CULVER DR NE STE 3
PALM BAY FL
32907-1104
US

IV. Provider business mailing address

1917 WOODHAVEN CIR APT 99
ROCKLEDGE FL
32955-8012
US

V. Phone/Fax

Practice location:
  • Phone: 678-358-2738
  • Fax:
Mailing address:
  • Phone: 678-358-2738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: