Healthcare Provider Details

I. General information

NPI: 1528596210
Provider Name (Legal Business Name): BRITIAN WIGFALL BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 05/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 GA HIGHWAY 96
WARNER ROBINS GA
31088-2584
US

IV. Provider business mailing address

131 SHARON CIR
AMERICUS GA
31709-2721
US

V. Phone/Fax

Practice location:
  • Phone: 478-957-9898
  • Fax:
Mailing address:
  • Phone: 229-939-0315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: