Healthcare Provider Details

I. General information

NPI: 1740293257
Provider Name (Legal Business Name): WIGGINS PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 HALL ST
WIGGINS MS
39577-2107
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-528-9119
  • Fax: 601-528-9193
Mailing address:
  • Phone: 601-528-9119
  • Fax: 601-528-9193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHY FENDER
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-947-8181