Healthcare Provider Details

I. General information

NPI: 1831828383
Provider Name (Legal Business Name): JWIGGINSBUSINESSINABOX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2722 CATALINA AVE
CHARLOTTE NC
28206-2237
US

IV. Provider business mailing address

7917 SUTTONVIEW DR
CHARLOTTE NC
28269-5236
US

V. Phone/Fax

Practice location:
  • Phone: 413-222-3267
  • Fax:
Mailing address:
  • Phone: 413-222-3267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JADA MAHOGANY WIGGINS
Title or Position: OWNER
Credential:
Phone: 413-222-3267